Biomedical subjects

James M Church

Publications and source records attributed to James M Church.

At least 19 recordsLinked to original sources

PubMed2007

Clinical outcomes and cost analysis of a "fast track" postoperative care pathway for ileal pouch-anal anastomosis: a case control study.

PURPOSE: Traditional length of hospital stay after ileal pouch-anal anastomosis is 8 to 15 days. Fast track rehabilitation programs reduce stay, but there are concerns that readmission and complication rates may be increased. This study evaluated a fast track pathway after ileoanal pouch surgery. METHODS: One hundred three consecutive patients underwent ileal pouch-anal anastomosis on two colorectal services using a fast track protocol with early ambulation, diet, and defined discharge criteria. Direct hospital costs and 30-day and long-term complication data were collected. Patients were matched to controls managed with traditional care pathways by other colorectal staff. RESULTS: Matching was established for 97 patients. Fast track patients had shorter hospital stay than controls (median 4 vs. 5 days; mean 5.0 vs. 5.9, P = 0.012). Readmission and recurrent operation rates were similar (24 vs. 20 percent, P = 0.49, and 9 vs. 10 percent, P = 0.8, fast track vs. control, respectively). Median direct costs per patient (US$) within 30 days were lower with fast track (5692 vs. 6672, P = 0.001), primarily because of reductions in postoperative management expenses. Complication rates, including pouch failure, bowel obstruction, pouchitis, and anastomotic stricture were comparable. Early discharge (< or = 5 days from surgery) occurred in 79 (77 percent) fast track patients. Failure with early discharge was associated with male gender, reoperations, and anastomotic complications. CONCLUSIONS: Fast track protocol after ileoanal pouch surgery reduces length of stay and hospital costs without increasing complication rates. Successful early discharge usually signals a benign postoperative course.

Adult↗

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↗

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

A scoring system for the strength of a family history of colorectal cancer.

BACKGROUND: Family history of colorectal cancer is associated with an increased risk for the disease, although there are many combinations of family history that are hard to correlate with risk status. A scoring system for family history of colorectal cancer was designed to make risk more readily quantifiable. METHODS: A colonoscopy database was used to test the following points system: each first-degree relative with colorectal cancer = 3 points; each second-degree relative with colorectal cancer = 1 point. Families with one or more first-degree relative affected under 50 years of age = an extra 3 points. Families with one or more second-degree relative affected under 50 years of age = an extra 1 point. Families with multiple relatives on the same side of the family = an extra 3 points (first-degree relatives), 1 point (second-degree relatives), or 2 points (first-degree and second-degree relatives). Points were added and categories defined as follows: low risk, 1 to 4 points; medium risk, 5 to 7 points; high risk, 8 to 10 points; very high risk, >10 points. A control group of average-risk patients having screening colonoscopy was used. Categories were compared in number of adenomas, hyperplastic polyps, and cancers. RESULTS: The records of 992 patients were used to test the system. Mean adenomas per patient per group were 0.4 for controls, 1.0 for low risk, 1.0 for medium risk, 1.7 for high risk, and 1.7 for very high risk. Cancers per group were 2 of 196 for controls, 8 of 513 for low risk, 3 of 171 for medium risk, 3 of 84 for high risk, and 1 of 28 for very high risk. The score categories were combined to produce revised risk levels of low (score 1 to 7) and high (>7). Average adenomas per patient in the revised categories were 0.4 (control), 1.0 (low risk), and 1.7 (high risk). The odds ratio of having one to two adenomas was 1.73 (1.19-2.50, 95% confidence limits) in the low-risk group and 2.39 (1.41-4.01) in the high-risk group. Odds ratios for having three or more adenomas were 5.70 (2.44-13.32) in the low-risk group and 10.35 (3.97-26.97) in the high-risk group. CONCLUSION: In the two-category system proposed here of quantifying familial risk of colorectal cancer, patients having less than 8 points were at low risk and those with 8 or more were at high risk. Surveillance and chemoprevention protocols can be designed through use of these risk categories. A scoring system for family history of colorectal cancer can make risk assessment easier and facilitate both collaborative studies and patient triage into appropriate screening programs.

Adenoma↗

PubMed2005

Laparotomy for acute colorectal conditions in moribund patients: is it worthwhile?

INTRODUCTION: Colorectal surgeons are sometimes asked to operate on moribund patients, classified by the American Society of Anesthesiology as Class 5--patients who are likely to die with or without surgery. There is a concern that surgery may precipitate the patient's demise; however, there are few data concerning outcomes in this group. It is, therefore, difficult to counsel patients and their families about the advisability of surgery. This study was performed to show what sort of results can be expected from operating on American Society of Anesthesiology Class 5 patients and to see whether there are any factors that can be used to predict outcome within this American Society of Anesthesiology class. METHODS: Since March 1989, a prospective database of all surgeries has been maintained. Included in the data is the American Society of Anesthesiology Classification. All patients classified as 5 were identified and their history reviewed. The 30-day postoperative survival was the primary end point of the study. Also abstracted were data on comorbidity, indication for colorectal surgery, surgery performed, length of postoperative hospital stay, estimated intraoperative blood loss, and duration of anesthesia. RESULTS: There were 4,163 surgeries recorded, including 2,040 (49 percent) laparotomies. There were 21 laparotomies in American Society of Anesthesiology Class 5 patients (1 percent of all laparotomies). Eighteen surgeries were performed as emergencies, and three were urgent. Nine patients survived 30 days or longer (41 percent), whereas 12 did not. Seven patients lived to be discharged from the hospital. CONCLUSION: Expeditious, safe surgery may save moribund patients with an acute colorectal problem.

Acute Disease↗

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

Evaluation of the learning curve in ileal pouch-anal anastomosis surgery.

SUMMARY BACKGROUND DATA: We define the learning curve required to attain satisfactory training in ileal pouch-anal anastomosis (IPAA) and identify possible differences in the learning curve for stapled and hand-sewn IPAA surgery. Various studies have addressed the differences in failure rate between stapled and hand-sewn IPAA, but there is no literature that evaluates the differences in attaining satisfactory training in each of these techniques. METHODS: Data were collected from 1965 patients undergoing IPAA surgery by 12 surgeons in a single center between 1983 and 2001. Using ileoanal pouch failure as the primary end point, a parametric survival model was used to adjust for case mix (patient comorbidity, preoperative diagnosis, manometric findings, and prior anal pathology). A risk-adjusted cumulative sum (CUSUM) model was used for monitoring outcomes in IPAA surgery. RESULTS: The 5-year ileal pouch survival was 95.6% (median patient follow-up of 4.2 years; range 0-19 years). Fifty percent of trainee staff demonstrated a learning curve in IPAA surgery. Having adjusted for case mix, trainee staff undertaking stapled IPAA surgery showed an improvement in the pouch failure rate following an initial training period of 23 cases versus 40 cases for senior staff. The learning curve for hand-sewn IPAA surgery was quantified only for senior staff who attained adequate results following an initial period of 31 procedures. CONCLUSIONS: The CUSUM method was a useful tool for objectively measuring performance during the learning phase of IPAA surgery. With adequate training, supervision, and monitoring, the learning curve in IPAA surgery may be reduced even further.

Adult↗

PubMed2004

Flat lesions of the colorectal mucosa: differences in recognition between Japanese and American endoscopists.

INTRODUCTION: Flat lesions of the colorectal mucosa have been a topic of debate since they were first described. Japanese series suggest that flat adenomas represent up to 25 percent of all colorectal adenomas and that they are a particularly advanced form of neoplasia for their size. Series published by Western endoscopists show a lower incidence and a lower degree of dysplasia. We performed this study to see whether American colonoscopists interpret the shape of lesions of the colorectal mucosa differently from their Japanese colleagues. METHODS: A book of endoscopic photographs of 50 small lesions of the colorectal mucosa was shown to 11 American and 8 Japanese colonoscopists. The colonoscopists were asked to decide whether each lesion was sessile, flat, depressed, pedunculated, or that there was no polyp present. Results were tabulated by lesion and by endoscopist. RESULTS: Although the average number of lesions deemed sessile was similar between groups (American, 33.8 +/- 2.1 95 percent confidence interval; Japanese, 29.4 +/- 2.2) there were marked differences in determination of flat lesions (American, 5.3 +/- 1.5; Japanese, 14.5 +/- 2.2), depressed lesions (American, 0.8 +/- 0.4; Japanese, 2.4 +/- 0.7) and those deemed "no polyp" (American, 5.1 +/- 0.9; Japanese 0). At least six of the eight Japanese colonoscopists agreed that a particular lesion was flat on 12 occasions, but American colonoscopists agreed on only 1 of these. Six of eight Japanese colonoscopists agreed on lesions as sessile in 27 cases, with Americans agreeing in 25 of these. CONCLUSIONS: There are significant differences in interpretation of the shape of lesions of the colorectal mucosa between Japanese colonoscopists and their American counterparts. These differences are likely to account for some of the apparent differences in incidence in series of flat colorectal adenomas reported from Japan and Western countries.

Adenoma↗

PubMed2004

Clinical significance of small colorectal polyps.

PURPOSE: Since the concept of "advanced" or "dangerous" adenomas was introduced in 1992, less concern has been directed to diminutive colorectal adenomas. They apparently confer no increased risk of metachronous colorectal cancer and some investigators have suggested that they need neither follow-up nor treatment. This study is intended to discover how often small colorectal adenomas have unfavorable histologic features. METHODS: Since 1995 the details of all colorectal polyps have been entered into a database, along with data concerning patients, symptoms, treatment, and outcome. Using this database all adenomas were categorized into three groups: Group I, <6 mm diameter, Group II, 6 to 10 mm diameter, and Group III, >10 mm diameter. "High risk" adenomas were defined as those containing >25 percent villous architecture, those with severe dysplasia, and those over 10 mm in size. Thus all Group III adenomas are high-risk by definition. The effects of family history, patient age, and polyp location on the proportions of Group I and Group II adenomas that were histologically high risk were examined. RESULTS: There were 5,722 polyps of which 4,381 (76.6 percent) were Group I, 666 (11.6 percent) were Group II, and 675 (11.8 percent) were Group III. These included 24 invasive cancers (2 in Group I, 1 in Group II, and 21 in Group III. Of the Group I adenomas, 91/2,064 (4.4 percent) were high risk compared to 65/417 (15.6 percent) in Group II. Of the 564 Group III adenomas, 326 (57.8 percent) had unfavorable histology. There was no effect of age, family history, or site of the polyp on the proportion of polyps that were high risk. CONCLUSIONS: Four percent of adenomas less than 6 mm diameter and 16 percent of those between 6 and 10 mm have unfavorable histology. Small adenomas can still be clinically significant and should not be ignored. Since the concept of "advanced" or "dangerous" adenomas was introduced in 1992, less concern has been directed to diminutive colorectal adenomas. They apparently confer no increased risk of metachronous colorectal cancer and some investigators have suggested that they need neither follow-up nor treatment. This study is intended to discover how often small colorectal adenomas have unfavorable histologic features.

Adenoma↗

PubMed2003

Dysplasia of the anal transitional zone after ileal pouch-anal anastomosis: results of prospective evaluation after a minimum of ten years.

PURPOSE: Stapling of the ileal pouch-anal anastomosis with preservation of the anal transitional zone remains controversial because of concerns about the potential risk of dysplasia and cancer. The natural history and optimal treatment of anal transitional zone dysplasia ten or more years after surgery are unknown. This study establishes the risk of dysplasia in the anal transitional zone and the outcome of a conservative management policy for anal transitional zone dysplasia, with a minimum of ten years' follow-up after ileal pouch-anal anastomosis. METHODS: A total of 289 patients undergoing anal transitional zone-sparing stapled ileal pouch-anal anastomosis for inflammatory bowel disease between 1986 and 1990 were studied. Patients undergoing anal transitional zone-sparing ileal pouch-anal anastomosis who were studied with serial anal transitional zone biopsies for at least ten years postoperatively were included (n = 178). Median follow-up was 130 (range, 120-157) months. RESULTS: Anal transitional zone dysplasia developed in 8 patients 4 to 123 (median, 9) months after surgery. There was no association with gender, age, preoperative disease duration, or extent of colitis, but the risk of anal transitional zone dysplasia was significantly associated with cancer or dysplasia as a preoperative diagnosis or in the proctocolectomy specimen. Dysplasia was high grade in two patients and low grade in six. Two patients with low-grade dysplasia on two or more occasions after detection of low-grade dysplasia underwent completion mucosectomy and perineal pouch advancement with neo-ileal pouch-anal anastomosis. One patient with high-grade dysplasia on two occasions was to undergo completion mucosectomy, but this was not technically feasible. Partial mucosectomy with vigorous anal transitional zone biopsy was performed with close postoperative surveillance. Biopsies were negative for dysplasia. The second recently diagnosed patient with high-grade dysplasia underwent examination under anesthesia with negative anal transitional zone biopsies and will be kept under close surveillance. No cancer in the anal transitional zone was found during the study period. The 4 other patients with low-grade dysplasia on 1 or 2 occasions were treated expectantly and have been dysplasia free for a median of 119 (range, 103-133) months. CONCLUSIONS: Anal transitional zone dysplasia after stapled ileal pouch-anal anastomosis is infrequent and is usually self-limiting. Anal transitional zone preservation did not lead to the development of cancer in the anal transitional zone with a minimum of ten years of follow-up. Long-term surveillance is recommended to monitor dysplasia. If repeat biopsy confirms persistent dysplasia, mucosectomy with perineal pouch advancement and neo-ileal pouch-anal anastomosis is recommended.

Adult↗

PubMed2003

Optimizing the outcome for patients with rectal cancer.

INTRODUCTION: Historically, rectal cancer with transmural spread and/or lymph node involvement has presented a major challenge to surgeons, with a variable and often high risk of local recurrence and poor survival outcomes. In recent years a large amount of literature has focused attention on the importance of surgical technique, tumor staging, and the optimal integration of CT and radiation therapy. METHODS: This article reviews the clinical trials that have defined the current approach to rectal cancer, the controversies regarding what should be considered the standard of care, and the ongoing clinical studies that will resolve some of these issues. RESULTS: The preoperative staging of rectal cancer can be improved with the use of endorectal ultrasound and (where available) magnetic resonance imaging. Careful pathologic analysis, particularly of the radial margin, provides important prognostic information that enables better allocation of postoperative care. Although both radiation therapy and CT have a proven role in adjuvant therapy, the interpretation of many studies is confounded by unacceptably poor outcomes in the control arm, and in older studies the use of inferior chemotherapy and radiation therapy techniques. Ongoing studies will better define the optimal combination and timing of chemotherapy and radiation therapy, with respect to both toxicity and survival endpoints. CONCLUSIONS: A combined modality approach to rectal cancer, integrating the colon and rectal surgeon, pathologist, medical oncologist, and radiation oncologist, is necessary to achieve optimal outcomes. The achievements to date and the ongoing vigorous debates regarding standard care continue to highlight the importance of quality ongoing research in a rapidly changing clinical environment.

Colectomy↗

PubMed2003

Colonic J-pouch-anal anastomosis for rectal cancer.

PURPOSE: The purpose of this article is to review the different aspects of the colonic J-pouch reconstruction with special focus on functional results and complications. METHODS: A MEDLINE search from 1965 to the present with manual search for older articles was used as the basis of this review. RESULTS: Rectal reconstruction using a colonic J-pouch-anal anastomosis after excision of extraperitoneal cancers can be performed with acceptable morbidity and good functional results. CONCLUSIONS: Among the different methods of rectal reconstruction now available after total rectal resection for cancer, the colonic J-pouch may be the optimal choice.

Anal Canal↗

PubMed2003

Anal transitional zone cancer after restorative proctocolectomy and ileoanal anastomosis in familial adenomatous polyposis: report of two cases.

PURPOSE: Restorative proctocolectomy with ileal pouch-anal anastomosis is accepted as the surgical treatment of choice for many patients with familial adenomatous polyposis. The risk of cancer developing in the ileal pouch after this surgery is unknown. Cancer may arise from the ileal pouch after restorative proctocolectomy, but that arising from the anal transitional zone has not been documented in familial adenomatous polyposis. We report two cases of this cancer from the anal transitional zone in patients with familial adenomatous polyposis, with a review of the literature. METHODS: All patients with familial adenomatous polyposis treated with restorative proctocolectomy and ileal pouch-anal anastomosis in The Cleveland Clinic were included in the study. Patients whose surveillance biopsy of the anal transitional zone revealed invasive adenocarcinoma were studied. RESULTS: Among a total of 146 patients with familial adenomatous polyposis who underwent restorative proctocolectomy and ileal pouch-anal anastomosis from 1983 to 2001 in our institution, none developed cancer of the anal transitional zone at up to 18 years of follow-up. However, there were two patients, both of whom underwent surgery elsewhere but who were followed up here, who developed invasive adenocarcinoma of the anal transitional zone. In one of them, cancer was diagnosed three years after a double-stapled ileal pouch-anal anastomosis, whereas in the other, cancer occurred eight years after a straight ileoanal anastomosis with mucosectomy. CONCLUSIONS: Cancer may develop in the anal transitional zone after restorative proctocolectomy with ileal pouch-anal anastomosis for familial adenomatous polyposis. Long-term surveillance of the anal transitional zone needs to be emphasized.

Adenocarcinoma↗

PubMed2003

Avoiding surgery in patients with colorectal polyps.

PURPOSE: Colonic polyps are sometimes difficult to remove endoscopically and are referred for surgical resection. This study was performed to determine how many polyps referred for surgery could actually be managed endoscopically. METHODS: An endoscopic database with data entered prospectively and consecutively was used to identify patients referred for surgery for a colonic polyp. Rectal polyps were excluded. All patients underwent colonoscopy before surgery to see if the polyp could be managed endoscopically. Cases were reviewed to see the method and outcome of treatment. RESULTS: The study population consists of 58 patients referred for surgical resection of a colorectal polyp. Endoscopic polypectomy was initially successful in 48. Five of the 48 needed surgery later for a final success rate of 43/58 avoiding surgery. There were no deaths, four complications of endoscopic polypectomy (three bleeds, one post-polypectomy syndrome) and two patients had complications of surgery (one splenic injury, one ventral hernia). Polyps ranged in size from 1.5 cm to 8.0 cm. Seven polyps contained invasive cancer (three needing surgical resection), eight contained intramucosal cancer (one operated) and 11 had severe dysplasia (three operated). Rate of persistent polyp was 16/37 at first follow up, 7/23 at second, 1/14 at third and 0/8 at fourth. CONCLUSION: Most polyps referred for surgical resection were successfully managed endoscopically. Patients with colonic polyps that are difficult or potentially dangerous to remove endoscopically should be sent for a second opinion before surgery is performed.

Aged↗

PubMed2003

Experience in the endoscopic management of large colonic polyps.

BACKGROUND: Large colonic polyps present a particular challenge to endoscopists because of the risks of significant haemorrhage, perforation, inadequate polypectomy, or trying to snare an unrecognized cancer. The alternative to endoscopic therapy of large polyps is surgical resection and although minimally invasive techniques are available, risks are significant. Although neither surgery nor endoscopy is a perfect way of treating large colonic polyps, endoscopic resection is usually tried first. Most series of endoscopic polypectomies are small, include both rectal and colonic polyps and have varying size and shape criteria. The purpose of the present study is to describe a large consecutive series of colonic polyps evaluated endoscopically, to determine the chances of performing a safe, effective endoscopic polypectomy. METHODS: All colonic polyps>20 mm in maximum dimension assessed during colonoscopy from 1989 to 2002 were reviewed. Rectal polyps were excluded. Demographic data for the patients were abstracted, as were data regarding the outcomes of polyp assessment and treatment. Primary end-points were: the need for surgical resection, the incidence of postpolypectomy complications and the persistence of the index polyp at follow up. Independent variables included the endoscopically assessed size of the polyps, the year in which the polypectomy took place, the shape of the polyps and their location within the colon. RESULTS: During the period under review 311 large polyps were removed from 252 different patients. Of these, 263 polyps were removed endoscopically and 48 polyps were removed surgically. An additional 18 endoscopically removed polyps ultimately needed surgery for recurrence or malignancy. There were no deaths but 19 complications of endoscopic polypectomy (17 late haemorrhage and two postpolypectomy syndrome). At first follow up, 22% of polyps had persisted, this decreased to 14% at second follow up and 7% at third. Complications were more common in right sided polyps and in flat or sessile lesions. Pedunculated polyps never persisted or recurred and had the lowest rate of surgery. Larger polyps had higher rates of advanced histology, complications, polyp persistence and the need for surgery. CONCLUSIONS: Polyp size, location and shape influence the results of endoscopic resection of large colonic polyps. Polyps>30 mm in maximum diameter are significantly more advanced histologically but also significantly more difficult to treat successfully than those <30 mm. However, size alone is rarely a contraindication to endoscopic resection.

Aged↗

PubMed2003

Prospective, age-related analysis of surgical results, functional outcome, and quality of life after ileal pouch-anal anastomosis.

OBJECTIVE To evaluate how age affects functional outcome and quality of life after ileal pouch anal anastomosis (IPAA). SUMMARY BACKGROUND DATA Because of the limited number of older patients undergoing IPAA, it has been difficult to assess functional outcome and quality of life stratified by age. METHODS IPAA was performed in 1895 patients. Patients were stratified by age into <45 (n = 1410), 46-55 (n = 289), 56-65 (n = 154), and more than 65 years (n = 42). Outcome was assessed prospectively. Results are presented at 1, 3, 5, and 10 years after surgery.RESULTS Patients were followed for 4.6 +/- 3.7 years (maximum, 17 years). Pouch failure occurred in 4.1% (pouch excision or permanent diversion). Incontinence and night time seepage were more common in older patients. There were minor differences in the quality of life, health, energy and happiness between age groups, with a slight benefit for those under 45 years. Fourteen percent or fewer patients experienced social, sexual or work restrictions. Overall, 96% of patients were happy to have undergone their surgery, and 98% recommended it to others. Although the respective figures were 89% and 96% in the over-65 age group, the difference was not significant. CONCLUSIONS These data provide a unique assessment of outcome after IPAA at multiple time points. Although functional outcome after IPAA is not as good in older patients, appropriate case selection confers acceptable function and quality of life to patients of all ages.

Adenomatous Polyposis Coli↗