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PubMed2005

Persistence of high CD40 and CD40L expression after restorative proctocolectomy for ulcerative colitis.

AIM: To focus on the role of CD40 and CD40L in their pathogenesis. METHODS: We analyzed by immunohistochemistry the CD40 and CD40L expression in the pouch mucosa of 28 patients who had undergone RPC for UC, in the terminal ileum of 6 patients with UC and 11 healthy subjects. We also examined by flow cytometry the expression of CD40 by B lymphocytes and monocytes in the peripheral blood of 20 pouch patients, 15 UC patients and 11 healthy controls. RESULTS: Ileal pouch mucosa leukocytes presented a significantly higher expression of CD40 and CD40L as compared to controls. This alteration correlated with pouchitis, but was also present in the healthy pouch and in the terminal ileum of UC patients. CD40 expression of peripheral B lymphocytes was significantly higher in patients with UC and pouch, respect to controls. Increased CD40 levels in blood B cells of pouch patients correlated with the presence of spondyloarthropathy, but not with pouchitis, or inflammatory indices. CONCLUSION: High CD40 expression in the ileal pouch mucosa could be implied in the pathogenesis of pouchitis following proctocolectomy for UC, whereas its increased levels on peripheral blood B lymphocytes are associated with the presence of extraintestinal manifestations.

Adult↗
PubMed2002

Anal complications after restorative proctocolectomy (J-pouch).

A prospective assessment was performed to determine the incidence of anal complications after ileoanal J-pouch anastomosis procedures for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). From 1989 to 2000, 75 patients (50 male and 25 female) underwent proctocolectomy and ileal pouch-anal anastomosis with temporary loop ileostomy for UC (N = 68) and FAP (N = 7). Overall 33 patients (44%) developed anal complications postoperatively. Nineteen patients (25%) had mild anal stenosis amenable to digital dilatation in the office. Ten patients (13%) had severe anal stenosis requiring operative dilatation. Ileostomy closure was delayed longer than 3 months in four patients because of anal stenosis. One patient never had his ileostomy closed secondary to severe anal stenosis. Anal fissures developed in one patient that resolved with conservative treatment. Three patients developed fistula-in-ano and one patient developed a pouch-vaginal fistula. Of these four patients two later manifested signs of Crohn's disease. Four patients developed perirectal abscesses (three without fistulas) that were treated with incision and drainage. Two patients had presacral (anastomotic) abscesses; one patient was treated with temporary anastomotic diversion and the other underwent a permanent ileostomy and pouch resection. Both of these patients were later diagnosed with Crohn's disease. Anal complications developed in 17 of 41 (41%) handsewn anastomoses, 16 of 34 (47%) stapled anastomoses, three of seven (43%) patients with FAP, and 30 of 68 (44%) patients with UC. Operative technique and disease type did not significantly correlate with the type of anal complication. However, hand-sewn anastomoses had a higher incidence of severe strictures and FAP patients did not develop anal abscesses, fistulas, or fissures. Forty-five per cent of our patients with abscesses/fistulas and all of our patients with presacral abscesses from anastomotic dehiscence were later diagnosed with Crohn's disease. Anal complications after ileoanal J-pouch anastomosis are relatively common.

Abscess↗
PubMed1994

Biochemical laboratory data in patients before and after restorative proctocolectomy. A study on 83 patients with a follow-up of 36 months.

From 1980 to 1987 ileoanal pouches were made in 83 patients. Specimen for a set of laboratory analyses were taken preoperatively, during the ileostomy and loop ileostomy periods and repeatedly during 36 months of follow-up. Cobalamine absorption and 14C-triolein breath tests were performed preoperatively in electively operated patients and postoperatively in all patients at 12 and 36 months. Low S-Ca was most pronounced preoperatively in patients who were to undergo acute colectomy (53%). Decreased S-Mg was detected in 16-36% at all stations. None had signs or symptoms of hypomagnesemia. Low S-albumin was rarely seen except for preoperatively in acute patients. Increased IgM was found in 40% of the patients during the loop ileostomy phase compared to 6-10% preoperatively. Substantially increased orosomucoid and/or haptoglobin were seen in patients during the functional periods but these increased values could not be correlated to episodes with acute pouchitis. High values of S-ALAT and ALP were much more frequent during the loop ileostomy periods than it was preoperatively and during pouch function. Low S-haemoglobin and/or iron were noticed during the functional period in 3-8% and 10-16%, respectively. Severe anaemia, due to iron deficiency developed in one patient after 2.5 years of pouch function. Preoperatively, slight decreases of S-B12 were found in 13% and impaired cobalamine absorption was revealed in 38% of the electively operated patients. The corresponding figures were 3% and 31% after 12 months and 5% and 36% after 36 months of follow-up, respectively. B12 substitution was given to in all 8 patients during the follow-ups. Lipid absorption was disturbed in 38% preoperatively and in 35% and 41% at 12 and 36 months, postoperatively.

Adenomatous Polyposis Coli↗
PubMed1993

[Restorative proctocolectomy: which kind of reservoir?].

Functional results after ileoanal anastomosis are better when a reservoir is used than when a straight reconstruction is carried out. Designs include the three loop (S) with and without a distal ileal segment, two loop (J), four loop (W) and lateral isoperistaltic (H). The evidence available indicates that frequency of defecation is inversely related to the size of the reservoir. It has also shown that a distal ileal segment may relate to failure of spontaneous evacuation. Non randomised studies suggest that larger reservoirs (eg S or W) give better results than a J reservoir. There is no apparent difference in the mobility of the reservoir to descend to the anal level whatever construction is used. Te particular design probably does not matter greatly provided: a) the reservoir is of sufficient capacity (three or four loop, or long double loop), and b) evacuation is facilitated by joining the pouch directly to the anus, thereby avoiding a distal ileal segment.

Fecal Incontinence↗
PubMed1995

[Restorative proctocolectomy for ulcerative colitis and familial polyposis].

From 1987-1994 we performed 35 proctocolectomies with ileal pouch anal anastomosis. The indication for operation was ulcerative colitis in 29 and familial polyposis in 6. The mean ages at operation were 35 and 25 years, respectively. The most common postoperative complication was small bowel obstruction in 25% of the patients, requiring re-operation in half of them. The incidence of this complication may be reduced by operating in only 1 stage when possible, without creating a protective ileostomy. The second serious complication was pouchitis, in 17%, which was controlled by antibiotics. There has been no mortality. All patients, except for 2 with an S-shaped pouch, evacuate spontaneously a mean of 5 bowel movements a day. Continence was mildly impaired (usually night-staining of a pad) in 30% of patients in whom the pouch-anal anastomosis was performed after stripping the mucosa of the rectal remnant. In those in whom the pouch-anal anastomosis was performed by means of the double stapling technique, continence was almost completely preserved. We therefore recommend that proctocolectomy with ileal pouch-anal anastomosis be performed in 1 stage when possible, using the double stapling technique. Staged operation should be reserved for severely ill patients, or when stripping of the rectal mucosa is performed for familial polyposis and ulcerative colitis with severe dysplasia.

Adenomatous Polyposis Coli↗
PubMed1996

Outcome of restorative proctocolectomy with ileal reservoir for ulcerative colitis: comparison of distal colitis with more proximal disease.

BACKGROUND: An increasing number of patients with severe or refractory ulcerative colitis involving only the rectum and sigmoid colon are being offered restorative proctocolectomy with ileal reservoir but very few data are available concerning the outcome for these patients. AIM: This study was designed to compare the outcome of ileal pouch procedures for distal ulcerative colitis with procedures performed for more extensive disease. PATIENTS: A consecutive series of 177 patients undergoing restorative proctocolectomy for ulcerative colitis between January 1984 and December 1994. METHODS: Data were collected prospectively in a dedicated ileal pouch database and included demographic details, indication for surgery, surgical procedures performed, early (< 30 days) and late morbidity, functional outcome, and histopathology. RESULTS: There was no mortality in the series. The incidence and range of early morbidity (< 30 days) and the functional outcome (daytime stool frequency, nocturnal frequency, and the incidence of incontinence) were similar for all groups. Log rank analysis of Kaplan-Meier estimates showed no significant difference between groups in the likelihood of developing pouchitis (p > 0.2). CONCLUSIONS: Patients undergoing restorative proctocolectomy for distal colitis experience a similar outcome to patients with more extensive disease. These data refute the hypothesis that pouchitis is more common in patients with total colitis.

Adolescent↗
PubMed1997

Functional results after restorative proctocolectomy complicated by pouchitis.

UNLABELLED: This study aimed to examine the incidence and cumulative risk of pouchitis after restorative proctocolectomy for ulcerative colitis and to evaluate the clinical and functional results in patients with pouchitis. METHODS: A total of 291 patients had proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis between January 1985 and January 1996. During follow-up, 65 patients had one or more episodes of pouchitis based on clinical, histologic, and endoscopic criteria. Functional results and patient satisfaction in these patients were compared with those of 65 matched control patients who had experienced no episodes of pouchitis. RESULTS: Pouchitis developed in 65 patients (22 percent), giving rise to a cumulative frequency of 28 percent at 11 years after the operation. Only 13 patients (4.5 percent) had chronic pouchitis that required long-lasting treatment. A permanent ileostomy had to be constructed in one patient (0.3 percent) because of pouchitis. During the last year (1995), 60 percent of patients with pouchitis had medication, most often metronidazole and/or corticosteroids. Defecation frequency per 24 hours was 6.7 for all patients with pouchitis, 8.2 for those with chronic pouchitis (P < 0.05), and 6.3 for patients without pouchitis. Nighttime defecation occurred in 44 (80 percent) patients with pouchitis, compared with 37 (67 percent) of those without pouchitis (P > 0.05). Frequencies of soiling or flatus incontinence did not differ between the two groups. During the last year, 43 (80 percent) of the pouchitis patients, who answered the questionnaire, were working all the year or were on sick-leave less than one month. CONCLUSIONS: Episodic pouchitis is easily treated and causes minimum functional consequences, whereas chronic pouchitis increases defecation frequency and needs prolonged medication. Pouchitis seems not to be a major threat to preventing the use of restorative proctocolectomy in ulcerative colitis, but still the small group of chronic pouchitis patients remains a problem.

Adolescent↗
PubMed1986

Restorative proctocolectomy. Clinical results and manometric findings with long and short rectal cuffs.

Clinical results and manometric findings were compared in 82 patients following restorative proctocolectomy. There were 41 patients with long rectal cuffs measuring 8 to 10 cm. There were 39 J-shaped pouches and 2 S-shaped pouches in this group. Forty-one patients had short rectal cuffs measuring 2 to 3 cm. There were 28 J-shaped pouches and 13 S-shaped pouches in this group. Anal manometry was performed in ten patients with long rectal cuffs and in ten patients with short rectal cuffs matched for age, sex, and stool frequency. Postoperative complications were significantly greater in patients with long rectal cuffs. Functional results and manometric findings were similar. No patient demonstrated a normal rectoanal inhibitory reflex. The data in this study suggest that a short rectal cuff can be used safely for restorative proctocolectomy with satisfactory results. A normal rectoanal inhibitory reflex may be absent after restorative proctocolectomy, and this does not interfere with the attainment of continence.

Adult↗
PubMed2007

Ten years experience of one-stage restorative proctocolectomy for ulcerative colitis.

BACKGROUND: Ileal-pouch anal anastomosis has an established role in the treatment of ulcerative colitis. Controversy exists regarding the routine use of a diverting ileostomy. The aim of this study was to review the clinical and functional outcome of patients undergoing restorative proctocolectomy in the absence of a diverting ileostomy (one-stage). MATERIALS AND METHODS: Between 1990 and 1999, 87 patients with ulcerative colitis underwent a one-stage restorative proctocolectomy. The median age at the time of operation was 34 years (range 12-64 years) and median follow-up was 36 months (range 24-144 months). The clinical notes were reviewed retrospectively. RESULTS: The median in-patient stay was 15 days (range 9-36). There were no post-operative deaths. The complication rate within 30 days of surgery approximated to 40%. The median daytime pouch evacuation rate was 5. Only 13% of patients had to empty their pouch at night on a regular basis. Pelvic sepsis secondary to anastomotic leakage was the most commonly encountered problem, occurring in 15 patients. Small bowel obstruction was encountered in ten patients. One pouch required excision for a recurrent pouch-vaginal fistula. CONCLUSION: Despite refinements in the surgical technique, restorative proctocolectomy is associated with significant morbidity. For a selected group of patients undergoing an ileo-anal anastomosis, a defunctioning ileostomy may be avoided.

Adolescent↗