Biomedical subjects

Feza H Remzi

Publications and source records attributed to Feza H Remzi.

At least 19 recordsLinked to original sources

PubMed2007

Risk factors for anemia in patients with ileal pouch-anal anastomosis.

PURPOSE: Anemia is frequently observed in patients with ileal pouch-anal anastomosis. The identification of the underlying causes can be challenging. This study was designed to define the prevalence and to identify etiologic factors for anemia in this patient population. METHODS: A prospectively maintained database and medical records of patients who had restorative proctocolectomy between 1998 and 2005 were reviewed. All patients with laboratory evaluation at least six months after the surgery were studied. The last reported hemoglobin served as the index value. All patients with anemia (hemoglobin < 13.5 g/dl for males, <12 g/dl for females) were identified. A second group of randomly selected, ileal-pouch patients with normal hemoglobin served as control. Demographic and clinical variables were evaluated. RESULTS: A total of 389 patients (214 males) had documented hemoglobin values. Sixty-seven patients (17 percent; 40 males) had anemia. The prevalence of anemia was 19 and 15 percent in males and females, respectively. The prevalence was 17 percent among patients with underlying ulcerative colitis vs. 26 percent in patients with familial adenomatous polyposis (P = 0.27). The mean hemoglobin in the anemia group was 11.4 (median, 11.7) g/dl. One patient (2 percent) had severe (<7 g/dl), 11 (16 percent) had moderate (7-9.9 g/dl), and 55 (82 percent) had mild (> or =10 g/dl) anemia. One patient (2 percent) had macrocytic, 16 (24 percent) had microcytic, and 49 (74 percent) had normocytic anemia. Sixteen patients (24 percent) had unidentified causes for anemia. Multivariable analysis showed that the presence of malignancy or desmoid tumor and the J-pouch configuration were the only independent risk factors associated with anemia. CONCLUSIONS: Anemia is common in ileal-pouch patients. Malignancy or desmoid tumor and J-pouch configuration are independent risk factors for anemia. One-fourth of the patients with anemia have unclear etiology.

Anemia↗

PubMed2006

Clostridium difficile-associated pouchitis.

Pouchitis is the most common long-term sequela of ileal pouch-anal anastomosis (IPAA) following total proctocolectomy. No single pathogen is identified as being solely responsible for the pathogenesis of the disease. Here we describe a case of Clostridium difficile-associated pouchitis that was successfully treated with ciprofloxacin and tinidazole. Diagnosis and management of a patient with medically refractory pouchitis associated with Clostridium difficile infection is described. A 63-year-old male with underlying ulcerative colitis and IPAA presented with increased stool frequency and seepage for 2 months, which partially responded to oral metronidazole. While on the antibiotic therapy, pouch endoscopy was performed and showed severe pouchitis. Assays for Clostridium difficile toxins in stool specimens were positive. He was treated with a 4-week course of ciprofloxacin 500 mg BID and tinidazole 500 mg TID. His symptoms resolved within several days from the initiation of therapy. A repeat pouch endoscopy at week 5 showed a complete resolution of mucosal inflammation of the pouch, while tests for Clostridium difficile toxins became negative. Clostridium difficile-associated pouchitis is rare. However, Clostridium difficile infection should be excluded in patients with chronic refractory pouchitis.

Anti-Infective Agents↗

PubMed2006

Perioperative blood transfusions increase infectious complications after ileoanal pouch procedures (IPAA).

BACKGROUND AND PURPOSE: Assessment of risk factors associated with the use of perioperative allogeneic blood transfusion and the effect of transfusion on infectious complications after ileal pouch-anal anastomosis (IPAA). METHODS: All patients included had IPAA with ileostomy. They were divided into two groups: transfused (TRAN); nontransfused (NON). Data included age, gender, preoperative anemia (Hgb <9 l g/dl), operative blood loss, transfusion volume, incidence of postoperative infectious or anastomotic complications, and length of stay (LOS). RESULTS: The 1,202 patients eligible for the study were divided into: TRAN = 240 patients and NON = 962 patients. The patient age, sex, and preoperative steroid use were similar in both groups. Significantly, more patients in the TRAN group were anemic preoperatively (32 vs 11%; p<0.05) and the preoperative Hgb level was significantly lower in the TRAN (12.07; p<0.05 vs 13.34 g/dl). Transfusion was required more frequently in anemic patients (p<0.001). The overall infection rate was significantly higher in the TRAN (48.75 vs 11.22%, p<0.001), Anastomotic separation (10.83 vs 3.32%, TRAN and NON, respectively; p<0.001) and fistula formation percentage (20.8 vs 4.46%, TRAN and NON, respectively; p<0.001) was significantly higher in the TRAN group. Pelvic sepsis also occurred more frequent in TRAN (22.9 vs 4.2%, TRAN and NON, respectively; p<0.001). The incidence of any infectious complication at any site was higher in anemic patients irrespective of transfusion status (18.2 vs 2.8%, p<0.05). Transfusion was the only significant independent risk factor for postoperative infections. LOS was adversely affected by an infectious complication (9 vs 7 days, p<0.001). CONCLUSIONS: Preoperative anemia is a significant risk factor for perioperative transfusion with significant increase in postoperative infectious complications and anastomotic complications after IPAA. Strategies to correct preoperative anemia, refine indications for transfusion, and define the use of blood salvage techniques may be helpful in decreasing this risk.

Adult↗

PubMed2006

Long-term outcome and quality of life after continent ileostomy.

INTRODUCTION: This study was designed to evaluate long-term outcomes for patients undergoing Kock continent ileostomy, identify factors associated with adverse outcomes, and compare changes in quality of life after removal of the reservoir. METHODS: The records of all patients (n = 330) undergoing continent ileostomy at the Cleveland Clinic Foundation between 1974 and 2001 were reviewed. Patient-related, intraoperative, and postoperative factors were evaluated as predictor variables of long-term pouch survival. Quality of life was evaluated using the continent ileostomy surgery follow-up questionnaire and the Cleveland Global Quality of Life scale (n = 216). These were compared between patients with continent ileostomy (n = 181) and patients who underwent removal of the continent ileostomy and conversion to an end stoma (n = 35). RESULTS: The median patient follow-up was 11 (range, 1-27) years. The median revision-free pouch interval was 14 (95 percent confidence interval, 11-17) months. The 10-year and 20-year pouch survival was 87 and 77 percent, respectively. Patients had an average of 3.7(range, 1-28) complications and 2.9 (range, 1-27) pouch revisions during follow-up. On multivariate analysis, Crohn's disease (hazard ratio = 4.5), female gender (hazard ratio = 2.4), fistula development (hazard ratio = 3), and body mass index (hazard ratio = 2.4 per 5 unit increase) were independent predictors of pouch failure. Quality of life measurements for patients with a continent ileostomy were higher on all scales in comparison with patients who had the Kock reservoir and then reverted to a Brooke ileostomy. CONCLUSIONS: Despite the associated morbidity with continent ileostomy surgery, long-term results and quality of life were encouraging. Continent ileostomy may be offered as an attractive long-term option to select patients whose only alternative is an end ileostomy.

Adolescent↗

PubMed2006

The outcome after restorative proctocolectomy with or without defunctioning ileostomy.

PURPOSE: Controversy exists regarding the safety for omission of diverting ileostomy in restorative proctocolectomy because of fears of increased septic complications. This study was designed to evaluate the outcomes of restorative proctocolectomy in a consecutive series of patients by comparing postoperative complications, functional results, and quality of life in patients with and without diverting ileostomy. METHODS: Data regarding demographics, length of stay, surgical characteristics, and complications were reviewed and recorded according to the presence (n= 1,725) or absence (n = 277) of a diverting ileostomy at the time of pelvic pouch surgery. Criteria for omission of ileostomy included: stapled anastomosis, tension-free anastomosis, intact tissue rings, good hemostasis, absence of airleaks, malnutrition, toxicity, anemia, and prolonged consumption of steroids. Functional outcome and quality of life indicators were prospectively recorded and compared. RESULTS: Patients in the ileostomy group had greater body surface area and older mean age at time of surgery, were taking greater doses of steroids preoperatively, and required more blood transfusions at the time of surgery compared with the one-stage (P < 0.05). There were no differences between the two groups in septic complications (P > 0.05). Early postoperative ileus was more common in the one-stage group (P < 0.001). There were no differences between the groups in quality of life and functional outcomes. CONCLUSIONS: For carefully selected patients undergoing restorative proctocolectomy with ileal pouch-anal anastomosis, omission of diverting ileostomy is a safe procedure that does not lead to an increase in septic complications or mortality. Quality of life and functional results are similar to those who undergo ileal pouch-anal anastomosis with diversion, provided that certain selection factors are considered.

Adenomatous Polyposis Coli↗

PubMed2006

Evaluation of the risk of a nonrestorative resection for the treatment of diverticular disease: the Cleveland Clinic diverticular disease propensity score.

PURPOSE: The choice of operation for diverticular disease is a contentious issue, particularly in patients with acute symptoms. This study compares early outcomes between primary resection and anastomosis and Hartmann's resection and describes a propensity score for the selection of patients for nonrestorative procedures. METHODS: Data were collected from 731 patients undergoing primary resection and anastomosis (Group 1) and 123 patients undergoing primary Hartmann's resection (Group 2) for diverticular disease in a single tertiary referral center from January 1981 to May 2003. Multifactorial logistic regression was used to develop a propensity score for estimating the likelihood of performing a nonrestorative procedure. RESULTS: Operative 30-day mortality and surgical or medical complications were 0.7 percent, 26.0 percent, and 4.8 percent for primary resection and anastomosis and 12 percent, 43.9 percent, and 14.6 percent for Hartmann's resection, respectively (P < 0.001). There was no difference in the readmission rates between primary resection and anastomosis and Hartmann's resection (7.6 percent vs. 9.9 percent, P = 0.428). Laparoscopy was used for 32.7 percent of primary resection and anastomosis vs. 1.6 percent for Hartmann's resection (P < 0.001). Independent predictors in favor for Hartmann's resection were body mass index > or = 30 kg/m2 (odd's ratio = 2.32), Mannheim peritonitis index >10 (odd's ratio = 6.75), operative urgency (emergency, urgent vs. elective surgery, odd's ratio = 16.08 vs. 13.32), and Hinchey stage > II (odd's ratio = 27.82). The area under the receiver operating characteristic curve for the choice of operative procedure was 93.9 percent. CONCLUSIONS: Although Hartmann's resection was associated with a higher incidence of postoperative adverse events, the choice of operation was dependent on the patient presentation and intra-abdominal contamination, which can be quantified in the preoperative setting by the Cleveland Clinic diverticulitis propensity score.

Anastomosis, Surgical↗

PubMed2006

Primary resection with anastomosis vs. Hartmann's procedure in nonelective surgery for acute colonic diverticulitis: a systematic review.

PURPOSE: This study compares primary resection with anastomosis and Hartmann's procedure in an adult population with acute colonic diverticulitis. METHODS: Comparative studies published between 1984 and 2004 of primary resection with anastomosis vs. Hartmann's procedure were included. The primary end point was postoperative mortality. Secondary end points included surgical and medical morbidity, operative time, and length of postoperative hospitalization. Random effects model was used and sensitivity analysis was performed. RESULTS: Fifteen studies, including 963 patients (57 percent primary resection with anastomoses, 43 percent Hartmann's procedures), were analyzed. Overall mortality was significantly reduced with primary resection and anastomosis (4.9 vs. 15.1 percent; odds ratio = 0.41). Subgroup analysis of trials matched for emergency operations showed significantly decreased mortality with primary resection and anastomosis (7.4 vs. 15.6 percent; odds ratio = 0.44). No significant difference in mortality was observed in trials matched for severity of peritonitis Hinchey > 2 (14.1 vs. 14.4 percent; odds ratio = 0.85). Sensitivity analysis did not reveal significant heterogeneity between the studies for the primary outcome. CONCLUSIONS: Patients selected for primary resection and anastomosis have a lower mortality than those treated by Hartmann's procedure in the emergency setting and comparable mortality under conditions of generalized peritonitis (Hinchey > 2). The retrospective nature of the included studies allows for a considerable degree of selection bias that limits robust and clinically sound conclusions. This analysis highlights the need for high-quality randomized trials comparing the two techniques.

Acute Disease↗

PubMed2006

Risk factors for diseases of ileal pouch-anal anastomosis after restorative proctocolectomy for ulcerative colitis.

BACKGROUND & AIMS: Although pouchitis is considered the most common adverse sequela of ileal pouch-anal anastomosis (IPAA), inflammatory and noninflammatory conditions other than pouchitis are increasingly being recognized. The risk factors for these non-pouchitis conditions, including Crohn's disease (CD) of the pouch, cuffitis, and irritable pouch syndrome (IPS), have not been studied. The aim of this study was to assess risk factors for inflammatory and noninflammatory diseases of IPAA in a tertiary care setting. METHODS: The study consisted of 240 consecutive patients who were classified as having healthy pouches (N = 49), pouchitis (N = 61), CD of the pouch (N = 39), cuffitis (N = 41), or IPS (N =50). Demographic and clinical features were assessed to determine risk factors for each of these conditions by using logistic regression analysis. RESULTS: Risk factors remaining in the final logistic regression models were for pouchitis: IPAA indication for dysplasia (odds ratio [OR], 3.89; 95% confidence interval [CI], 1.69-8.98), never having smoked (OR, 5.09; 95% CI, 1.01-25.69), no use of anti-anxiety agents (OR, 5.19; 95% CI, 1.45-18.59), or use of NSAIDs (OR, 3.24; 95% CI, 1.71-6.13); for CD of the pouch: a long duration of IPAA (OR, 1.20; 95% CI, 1.12-1.30) and current smoking (OR, 4.77; 95% CI, 1.39-16.25); for cuffitis: arthralgias (OR, 4.13; 95% CI, 1.91-8.94) and younger age (OR, 1.16; 95% CI, 1.01-1.33); and for IPS: use of antidepressants (OR, 4.17, 95% CI, 1.95-8.92) or anti-anxiety agents (OR, 3.21; 95% CI, 1.34-7.47). CONCLUSIONS: The majority of risk factors for the 4 inflammatory and noninflammatory conditions of IPAA are different, suggesting that each of these diseases has a different etiology and pathogenesis. The identification and modification of these risk factors might help patients and clinicians to make a preoperative decision for IPAA, reduce IPAA-related morbidity, and improve response to treatment.

Adult↗

PubMed2006

Factors associated with failure in managing pelvic sepsis after ileal pouch-anal anastomosis (IPAA)--a multivariate analysis.

BACKGROUND: Pelvic sepsis is known to cause a detrimental outcome after ileal pouch-anal anastomosis (IPAA). The aim of this study was to examine potential factors associated with failure in managing pelvic sepsis after IPAA. METHODS: We performed univariate and multivariate logistic regression analysis on 2518 IPAA patients between 1983 and 2005. Failure was defined as pouch failure, the need for a permanent ileostomy, or mortality as a result of sepsis. There were 157 patients (6.2%) with pelvic sepsis after IPAA. These involved anastomotic leak 34% (54/157) and fistula 25% (40/157). There were 5 mortalities related to sepsis. Mean age at surgery was 38.1 +/- 14.4 years and mean follow-up was 5.5 +/- 4.7 years. RESULTS: Pouches were saved in 75.8% patients. Univariate analysis identified early sepsis (P = .040), preoperative steroid use (P = .007), and need for percutaneous drainage (P = .004) as significant factors associated with treatment success. Factors associated with failure were hypertension (P = .026), hand-sewn anastomosis (P = .038), associated fistula (P = .0003), need for transanal drainage (P = .0002), need for laparotomy to control septic complications (P < .0001), delayed ileostomy closure (P = .0003), and need for a new diverting ileostomy (P < .0001). By using multivariate analysis with selected covariates, significant factors associated with failure were associated fistula (P = .0013), need for transanal drainage (P = .003), delayed ileostomy closure (P = .022), need for a new ileostomy diversion (P = .004), and hypertension (P = .039). We developed a predictive scoring system for failure to use in management plans and decision-making for the treatment of septic complications of IPAA. CONCLUSIONS: Pelvic sepsis after IPAA has a significant impact on pouch failure. This predictive model for failure may play an important role in providing risk estimates for successful outcomes.

Abdominal Abscess↗

PubMed2006

Management of radiotherapy induced rectourethral fistula.

PURPOSE: An increasing number of men are being treated with BT or a combination of external beam radiation therapy and BT for localized prostate cancer. Although uncommon, the most severe complication following these procedures is RUF. We reviewed our recent experience with RUF following radiotherapy for prostate cancer to clarify treatment in these patients. MATERIALS AND METHODS: We recently treated 22 men with RUF following primary radiotherapy for adenocarcinoma of the prostate in 21 and adjuvant external beam radiation therapy following radical prostatectomy in 1. Time from the last radiation treatment to fistula presentation was 6 months to 20 years. RESULTS: Four patients underwent proctectomy with permanent fecal and urinary diversion. RUF repair in 5 patients was performed with preservation of fecal or urinary function. Six patients were candidates for reconstruction with preservation of urinary and rectal function, including 5 who underwent proctectomy, staged colo-anal pull-through and BMG repair of the urethral defect. The additional patient underwent primary closure of the rectum, BMG repair of the urethra and gracilis muscle interposition. Successful fistula closure was achieved in the 9 patients who underwent urethral reconstruction. All 8 candidates for rectal reconstruction showed radiological and clinical bowel integrity postoperatively with 2 awaiting final diverting stoma closure. CONCLUSIONS: With the increasing use of prostate BT the number of patients with severe rectal injury will likely continue to increase. Radiotherapy induced RUF carries significant morbidity and most patients are treated initially with fecal and urinary diversion. In properly selected patients good outcomes can be expected following repair using BMG for the urethral defect along with colo-anal pull-through or primary rectal repair and gracilis muscle interposition.

Adenocarcinoma↗

PubMed2006

A comparison of hand-sewn versus stapled ileal pouch anal anastomosis (IPAA) following proctocolectomy: a meta-analysis of 4183 patients.

OBJECTIVE: Using meta-analytical techniques, the study compared postoperative adverse events and functional outcomes of stapled versus hand-sewn ileal pouch-anal anastomosis (IPAA) following restorative proctocolectomy. BACKGROUND: The choice of mucosectomy and hand-sewn versus stapled pouch-anal anastomosis has been a subject of debate with no clear consensus as to which method provides better functional results and long-term outcomes. METHODS: Comparative studies published between 1988 and 2003, of hand-sewn versus stapled IPAA were included. Endpoints were classified into postoperative complications and functional and physiologic outcomes measured at least 3 months following closure of ileostomy or surgery if no proximal diversion was used, quality of life following surgery, and neoplastic transformation within the anal transition zone. RESULTS: Twenty-one studies, consisting of 4183 patients (2699 hand-sewn and 1484 stapled IPAA) were included. There was no significant difference in the incidence of postoperative complications between the 2 groups. The incidence of nocturnal seepage and pad usage favored the stapled IPAA (odds ratio [OR] = 2.78, P < 0.001 and OR = 4.12, P = 0.007, respectively). The frequency of defecation was not significantly different between the 2 groups (P = 0.562), nor was the use of antidiarrheal medication (OR = 1.27, P = 0.422). Anorectal physiologic measurements demonstrated a significant reduction in the resting and squeeze pressure in the hand-sewn IPAA group by 13.4 and 14.4 mm Hg, respectively (P < 0.018). The stapled IPAA group showed a higher incidence of dysplasia in the anal transition zone that did not reach statistical significance (OR = 0.42, P = 0.080). CONCLUSIONS: Both techniques had similar early postoperative outcomes; however, stapled IPAA offered improved nocturnal continence, which was reflected in higher anorectal physiologic measurements. A risk of increased incidence of dysplasia in the ATZ may exist in the stapled group that cannot be quantified by this study. We describe a decision algorithm for the choice of IPAA, based on the relative risk of long-term neoplastic transformation.

Anastomosis, Surgical↗

PubMed2006

Risk factors for clinical phenotypes of Crohn's disease of the ileal pouch.

BACKGROUND: Crohn's disease (CD) of the pouch can occur in patients with colectomy and ileal pouch-anal anastomosis (IPAA) originally performed for a preoperative diagnosis of ulcerative colitis. The clinical presentations of CD of the pouch are inflammatory, fibrostenotic, and fistulizing. Risk factors for clinical phenotypes of CD of the pouch have not been characterized. METHODS: A total of 78 eligible patients with CD of the pouch together with 294 nonselected non-CD patients with IPAA seen in the Pouchitis Clinic were enrolled, including 28 with inflammatory CD, 18 with fibrostenotic CD, and 32 with fistulizing CD. The clinical phenotypes of CD were diagnosed based on a combined assessment of clinical, endoscopic, radiographic, and histologic features. Three separate analyses were performed, and for each analysis, the outcome of interest was having one of the phenotypes versus not having it. A stepwise selection multivariable logistic regression analysis was used. RESULTS: In the multivariable analysis, the risk factor for inflammatory CD was higher afferent-limb endoscopy scores (hazard ratio [HR] 1.87 95% confidence interval [CI] 1.54-2.27); the risk factors for fibrostenotic CD were higher afferent-limb (95% CI 1.81-3.48, HR 2.51) and higher cuff (95% CI 1.01-1.84, HR 1.36) endoscopy scores; and for fistulizing CD the risk factors were younger age (95% CI 0.93-0.99, HR 0.96), female gender (95% CI 1.35-6.97, HR 3.07), a preoperative diagnosis of indeterminate colitis (95% CI 1.72-9.34, HR 4.00), and no use of nonsteroidal antiinflammatory drugs (95% CI 1.31-8.25, HR 3.28). CONCLUSIONS: Each of the three phenotypes of CD of the pouch was associated with certain risk factors, suggesting that each of these diseases has a different etiology and disease process. The identification and management of some of the modifiable risk factors may reduce CD-related morbidity.

Adult↗

PubMed2005

Recurrence after transanal excision of T1 rectal cancer: should we be concerned?

PURPOSE: Transanal excision is an appealing treatment for low rectal cancers because of its low morbidity, mortality, and better functional results than transabdominal procedures. However, controversy exists about whether it compromises the potential for cure. Several, recent reports of high recurrence rates after local excision prompted us to review our results of transanal excision alone in patients with T1 rectal cancers. METHODS: All patients with T1 low rectal cancer undergoing local excision alone between 1980 through 1998 were reviewed for local recurrence, distant metastasis, disease-free interval, results of salvage surgery, and overall and disease-free survival. Demographics, tumor size, distance from anal verge, and preoperative endoluminal ultrasound results also were recorded. Patients with poorly differentiated tumors, perineural or lymphovascular invasion, or with mucinous component were excluded. RESULTS: Fifty-two patients underwent transanal excision during the study period. Five-year recurrence was estimated to be 29.38 percent (95 percent confidence interval, 15.39-43.48). For 52 patients, five-year, cancer-specific and overall survival rates were 89 and 75 percent respectively. Fourteen of 15 patients with recurrence underwent salvage treatment with 56.2 percent (95 percent confidence interval, 35.2-90) five-year survival rate. Gender, preoperative staging by endorectal ultrasound, distance from the anal verge, tumor size, location, and T1 status discovered after transanal excision of a villous adenoma did not influence local recurrence or tumor-specific survival. CONCLUSIONS: Transanal excision for T1 rectal tumors with low-grade malignancy has a high rate of recurrence. Although overall cancer survival rates might be regarded as satisfactory, this high recurrence and low salvage rate raises the issue about the role of transanal excision alone for early rectal cancer and the possible need for adjuvant therapy or increased role of resective surgery.

Aged↗

PubMed2005

Colonic surgery in patients with juvenile polyposis syndrome: a case series.

PURPOSE: Juvenile polyposis syndrome is characterized by multiple hamartomatous polyps in the large intestine. When indicated, the surgical choices in symptomatic juvenile polyposis syndrome patients are colectomy with ileorectal anastomosis or proctocolectomy with pouch. The aim of this study was to evaluate the long-term outcomes of the surgical options in juvenile polyposis syndrome patients who present with symptomatic colonic polyps. METHODS: The charts of all juvenile polyposis syndrome patients who had had at least one colonic operation since 1953 in our institution were reviewed. The following data were abstracted: demographics, the number and site of the polyps, symptoms, the intervals and types of the colonic operation, follow-up, and the patients' current status. RESULTS: There were 13 patients (6 males) with a median age of 10 years (range, 1-50 years) at the time of diagnosis. Patients had colonic (n = 13), rectal (n = 12), and gastric (n = 6) polyps. Rectal bleeding (n = 11) was the most common presenting symptom. Three patients underwent proctectomy as the initial operation. Although a rectum-preserving operation was initially performed in ten patients, a subsequent proctectomy was required in five of them within a median of 9 years (range, 6-34 years). Therefore, eight patients had their rectum removed during the study period; five had an ileal pouch-anal anastomosis, one had a Koch pouch as a restorative surgery, and two had an end ileostomy. No relation was observed between the number of colonic and rectal polyps and the type of surgery or the need for proctectomy. Patients were followed up a median of 3 years (range, 2-24 years) after their ultimate operations. During this period, one patient (20 percent) who underwent restorative proctectomy and 4 patients (80 percent) whose rectums were preserved required multiple endoscopic polypectomies for recurrent polyps in the pouch (first patient) or their rectums (the other four patients). The patient who underwent the Koch procedure required surgery for recurrent polyps in her pouch. CONCLUSIONS: One-half of the patients who initially underwent rectal preservation required subsequent proctectomy. The number of colonic or rectal polyps does not influence the choice of the surgical procedure. Both restorative proctocolectomy and subtotal colectomy with ileorectal anastomosis need endoscopic follow-up because of the high recurrence rates of juvenile polyps in the remnant rectum or pouch.

Adenomatous Polyposis Coli↗

PubMed2005

Loop ileostomy closure after restorative proctocolectomy: outcome in 1,504 patients.

PURPOSE: Routine use of a temporary loop ileostomy for diversion after restorative proctocolectomy is controversial because of reported morbidity associated with its creation and closure. This study intended to review our experience with loop ileostomy closure after restorative proctocolectomy and determine the complication rates. In addition, complication rates between handsewn and stapled closures were compared. METHODS: Our Department Pelvic Pouch Database was queried and charts reviewed for all patients who had ileostomy closure after restorative proctocolectomy from August 1983 to March 2002. RESULTS: A total of 1,504 patients underwent ileostomy closure after restorative proctocolectomy during a 19-year period. The median length of hospitalization was three (range, 1-40) days and the overall complication rate was 11.4 percent. Complications included small-bowel obstruction (6.4 percent), wound infection (1.5 percent), abdominal septic complications (1 percent), and enterocutaneous fistulas (0.6 percent). Handsewn closure was performed in 1,278 patients (85 percent) and stapled closure in 226 (15 percent). No significant differences in complication rates and length of hospitalization were found between handsewn and stapled closure techniques. CONCLUSIONS: Our results demonstrated that ileostomy closure after restorative proctocolectomy can be achieved with a low morbidity and a short hospitalization stay. In addition, we found that complication rates and length of hospitalization were similar between handsewn and stapled closures.

Adolescent↗

PubMed2005

Quality of life, functional outcome, and complications of coloplasty pouch after low anterior resection.

PURPOSE: The colonic J-pouch has been used to improve bowel function in patients undergoing low colorectal or coloanal anastomosis. However, a narrow pelvis, difficulties in reach, a long anal canal with prominent sphincters, or a fatty mesentery may turn this technique into a technically challenging procedure in certain patients. In these circumstances, "coloplasty" offers an alternative to a straight anastomosis. The purpose of this study was to compare the quality of life, functional outcome, and complications between patients undergoing coloplasty, colonic J-pouch, or straight anastomosis. METHODS: Altogether, 162 patients who underwent coloanal or low colorectal anastomosis between 1998 and 2001 were studied. Data collected included demographics, length of follow-up, technique and type of anastomosis, complications, quality of life, and functional outcome. Results were analyzed according to use of a coloplasty (n = 69), colonic J-pouch (n = 43), or straight anastomosis (n = 50). The choice of the technique was based on the surgeon's preference. Usually coloplasty or straight anastomosis was favored in male patients with a narrow pelvis or when a handsewn anastomosis was used. RESULTS: Quality of life assessment with the short form-36 questionnaire revealed better scores in coloplasty and colonic J-pouch groups. The coloplasty (1.0 +/- 1.7) and colonic J-pouch (1.0 +/- 1.2) groups had fewer night bowel movements than the straight anastomosis group (1.5 +/- 2.0) (P < 0.05). The coloplasty group also had fewer bowel movements per day than the straight anastomosis group (3.8 +/- 2.9 vs. 4.8 +/- 3.6; P < 0.05); also, less clustering and less antidiarrheal medication use were observed than in the straight anastomosis group. Colonic J-pouch patients with handsewn anastomosis had a higher anastomotic leak rate (44 percent) than the patients in the coloplasty with handsewn anastomosis group (3.6 percent). CONCLUSIONS: Coloplasty seems to be a safe, effective technique for improving the outcome of low colorectal or coloanal anastomosis. It is especially applicable when a colonic J-pouch anastomosis is technically difficult.

Adult↗

PubMed2005

Vaginal delivery after ileal pouch-anal anastomosis: a word of caution.

PURPOSE: This study was designed to evaluate the impact of childbirth on anal sphincter integrity and function, functional outcome, and quality of life in females with restorative proctocolectomy and ileal pouch-anal anastomosis. METHODS: The patients who had at least one live birth after ileal pouch-anal anastomosis were asked to return for a comprehensive assessment. They were asked to complete the following questionnaires: the Short Form-36, Cleveland Global Quality of Life scale, American Society of Colorectal Surgeons fecal incontinence severity index, and time trade-off method. Additionally, anal sphincter integrity (endosonography) and manometric pressures were measured by a medical physician blinded to the delivery technique. Anal sphincter physiology also was evaluated with electromyography and pudendal nerve function by nerve terminal motor latency technique. RESULTS: Of 110 eligible females who had at least one live birth after ileal pouch-anal anastomosis, 57 participated in the study by returning for clinical evaluation to the clinic and 25 others by returning the quality of life and functional outcome questionnaires. Patients were classified into two groups: patients who had only cesarean section delivery after ileal pouch-anal anastomosis (n = 62) and patients who had at least one vaginal delivery after ileal pouch-anal anastomosis (n = 20). The mean follow-up from the date of the most recent delivery was 4.9 years. The vaginal delivery group had significantly higher incidence of an anterior sphincter defect by anal endosonography (50 percent) vs. cesarean section delivery group (13 percent; P = 0.012). The mean squeeze anal pressure was significantly higher in the patients who had only cesarean section delivery (150 mmHg) after restorative proctocolectomy than patients who had at least one vaginal delivery (120 mmHg) after restorative proctocolectomy (P = 0.049). Quality of life evaluated by time trade-off method also was significantly better in the cesarean section delivery group (1) vs. vaginal delivery group (0.9; P < 0.001). CONCLUSIONS: The risk of the sphincter injury and quality of life measured by time trade-off method are significantly worse after vaginal delivery compared with cesarean section in patients with ileal pouch-anal anastomosis. In the short-term, this does not seem to substantially influence pouch function or quality of life; however, the long-term effects remain unknown, thus obstetric concern may not be the only factor dictating the type of delivery in this group of patients. A planned cesarean section may eliminate these potential and factual concerns in ileal pouch-anal anastomosis patients.

Adult↗

PubMed2005

Hartmann's reversal is associated with high postoperative adverse events.

PURPOSE: The aim of this study was to ascertain the preva lence and pattern of surgical and medical adverse events in patients undergoing Hartmann's reversal for diverticular dis ease. A comparison of postoperative outcomes is made be tween Hartmann's reversal and primary resection and anas tomosis. METHODS: Data were collected from patients who underwent successful Hartmann's reversal (Group 1 n=121) and primary resection and anastomosis (Group 2 n=731) for diverticular disease in a single center from January 1981 to May 2003. Multivariate logistic regression was used to compare early postoperative mortality, medical and surgical complications and readmission rates between the two groups. RESULTS: Hartmann's reversal was associ ated with a higher prevalence of surgical or medical com plications compared with primary resection and anastomo sis (43.8 percent and 9.1 percent for Hartmann's reversal vs. 26.0 percent and 4.8 percent for primary resection and anastomosis). There was no difference in the readmissior rates (7.2 percent vs. 7.6 percent, respectively, P = 0.88) or early postoperative mortality (1.7 percent vs. 0.7 percent, P = 0.25) between Hartmann's reversal and primary resection and anastomosis. The need for reoperation, prolonged ileus respiratory tract infections, and renal failure were more common adverse events in the Hartmann's reversal group (P < 0.01). Having controlled for the number of comorbid conditions, extent of diverticular disease, severity of peri toneal contamination (Mannheim Peritonitis Index), and op erative urgency, patients who underwent Hartmann's rever sal were 2.1 times more likely to have adverse surgical events during their postoperative period (95 percent confidence interval for odds ratio = 1.3-3.3). CONCLUSIONS: Hartmann's reversal is a complex surgical procedure that is associated with a high prevalence of postoperative adverse events in comparison with primary resection and anastomosis. To minimize the prevalence of such adverse events, patients who undergo Hartmann's reversal need careful preoperative evaluation and close monitoring in their postoperative period.

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