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PubMed1994

Pouch-vaginal fistula after restorative proctocolectomy: aetiology and management.

Pouch-vaginal fistula is a rare complication following restorative proctocolectomy. Seven patients who developed such a fistula are presented. Six pouch-vaginal fistulas occurred at the level of the pouch-anal anastomosis and one 3 cm above the anastomosis, level with the posterior vaginal fornix. The anastomosis had been hand-sewn in four patients (following mucosectomy) and stapled in three. Five fistulas presented within the perioperative period (median 16 (range 10-30) days) and two at 186 and 273 days. Treatment was successful in the patients who presented early, and these remain continent with functioning pouches. If not already present (two patients), an ileostomy was raised. Repair was by endovaginal flap advancement, combined with fistulotomy and sphincter repair in two patients. Treatment was unsuccessful in the two patients who presented late; in both the diagnosis was revised to Crohn's disease, necessitating pouch excision.

Adolescent↗

PubMed2000

What is the benefit of preoperative sperm preservation for patients who undergo restorative proctocolectomy for benign diseases?

PURPOSE: In patients with benign colorectal diseases undergoing a restorative proctocolectomy with an ileal pouch-anal anastomosis, semen cryopreservation seems rational to enable the possibility of procreation in case surgery leads to sexual disorders or impotence. The aim of this study was to determine the preoperative and postoperative semen quality in patients undergoing ileal pouch-anal anastomosis. In addition, the study sought to determine the incidence of surgery-induced sexual dysfunction to evaluate the economic efficiency of semen cryopreservation as compared with alternatives such as microsurgical epididymal sperm aspiration. METHODS: Preoperative and postoperative semen analyses were offered to 97 patients with ileal pouch-anal anastomosis with benign colorectal diseases since 1989. The direct costs of the semen cryopreservation program were determined and compared with those of alternatives. RESULTS: In 34 of 40 consecutive patients with ileal pouch-anal anastomosis who made use of preoperative semen preservation, normal sperm concentrations, motility, and morphology were found. Mean semen characteristics of all 23 patients who returned for postoperative analysis were not different from preoperative values, but they were for total sperm number. Two patients developed temporary retrograde ejaculation postoperatively. None of the preserved semen samples was used, thus semen cryopreservation benefited none of these patients. The total costs of semen cryopreservation are between 2.2 and 5 times higher than the costs for one microsurgical epididymal sperm aspiration procedure. CONCLUSIONS: Preoperative semen cryopreservation in patients undergoing ileal pouch-anal anastomosis because of benign colorectal diseases is quite feasible. However, most likely because of improved surgical techniques and the increasing number of effective alternatives, preoperative semen cryopreservation in patients with ileal pouch-anal anastomosis is no longer cost effective.

Adult↗

PubMed1999

The use of an omental pedicle graft to prevent small-bowel obstruction after restorative proctocolectomy.

Small-bowel obstruction remains one of the most frequent complications after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). Of particular concern is small-bowel adhesion to the pelvic dead space that causes afferent limb obstruction, sometimes necessitating laparotomy. In this report, we describe a technique using an omental pedicle graft (OPG) to fill the pelvic dead space to prevent small-bowel obstruction and the resulting afferent limb obstruction after IPAA. The OPG is created from the left half of the omentum, while maintaining the blood supply from the left gastroepiploic vessels. The omentum is placed into the pelvis along the left paracolic gutter from where the colon has been resected. It is then passed over the pelvic brim and placed behind and along the bilateral sides of the ileal pouch, filling the space. This modified technique was employed in the treatment of four patients with chronic ulcerative colitis, none of whom developed any signs of small-bowel obstruction.

Chronic Disease↗

PubMed2006

Restorative proctocolectomy and ileal pouch-anal anastomosis for familial adenomatous polyposis revisited.

Since restorative proctocolectomy (RPC) with ileal-pouch anal anastomosis (IPAA) removes the entire diseased mucosa, it has become firmly established as the standard operative procedure of choice for familial adenomatous polyposis (FAP). Many technical controversies still persist, such as mesenteric lengthening techniques, close rectal wall proctectomy, endoanal mucosectomy vs. double stapled anastomosis, loop ileostomy omission and a laparoscopic approach. Despite the complexity of the operation, IPAA is safe (mortality: 0.5-1%), it carries an acceptable risk of non-life-threatening complications (10-25%), and it achieves good long-term functional outcome with excellent patient satisfaction (over 95%). In contrast to the high incidence in patients operated for ulcerative colitis (UC) (15-20%), the occurrence of pouchitis after IPAA seems to be rare in FAP patients (0-11%). Even after IPAA, FAP patients are still at risk of developing adenomas (and occasional adenocarcinomas), either in the anal canal (10-31%) or in the ileal pouch itself (8-62%), thus requiring lifelong endoscopic monitoring. IPAA operation does not jeopardise pregnancy and childbirth, but it does impair female fecundity and has a low risk of impairment of erection and ejaculation in young males. The latter can almost completely be avoided by a careful "close rectal wall" proctectomy technique. Some argue that low risk patients (e.g. <5 rectal polyps) can be identified where ileorectal anastomosis (IRA) might be reasonable. We feel that the risk of rectal cancer after IRA means that IPAA should be recommended for the vast majority of FAP patients. We accept that in some very selected cases, based on clinical and genetics data (and perhaps influenced by patient choice regarding female fecundity), a stepwise surgical strategy with a primary IPA followed at a later age by a secondary proctectomy with IPAA could be proposed.

Adenomatous Polyposis Coli↗

PubMed1994

Longterm appraisal of the histological appearances of the ileal reservoir mucosa after restorative proctocolectomy for ulcerative colitis.

Between November 1976 and December 1985, 110 patients had restorative proctocolectomy for ulcerative colitis. The histological appearances in the reservoir mucosa were followed up in 60 of 109 survivors over 19-173 months (median 97). The median number of biopsy specimens taken per patient was six with a range of 3-13. These were examined by one pathologist (ICT) unaware of the clinical details using a scoring system previously described to assess the degree of chronic and acute inflammation. There was a significant correlation between the degree of severity of chronic and acute changes (r = 0.6192, p < 0.000001). There was no correlation between the severity of inflammation and the following variables: preoperative duration of disease, presence of cancer or dysplasia in the original operative specimen, extra-alimentary manifestations or the type of reservoir. A significant correlation between severe inflammation and male sex was found (p < 0.035). The 60 patients could be divided into three groups based on the severity and fluctuation of histological inflammation. In group A (n = 27, 45%) chronic changes were minor and acute inflammation was never seen. In group B (n = 25, 42%) chronic changes were more severe and there were transient episodes of acute inflammation. In group C (n = 8, 13%) severe chronic and severe acute inflammation were constantly present. Differentiation of the three groups had clearly occurred within six months from closure of the ileostomy. Patients in group C could be identified on histological criteria within weeks of closure of the ileostomy and were those exclusively at risk of developing chronic pouchitis. Chronic pouchitis never occurred in patients of groups A and B. No case of dysplasia was seen. Histological assessment of the reservoir mucosa with in a few months after closure of the ileostomy seems to define patients who will and who will not subsequently develop pouchitis.

Adolescent↗

PubMed1999

Extraintestinal manifestations of ulcerative colitis following restorative proctocolectomy.

BACKGROUND: Rheumatological and other extraintestinal manifestations (EIM) are common in inflammatory bowel disease (IBD) but also seem to occur in patients after restorative proctocolectomy and formation of an ileo-anal pouch. The prevalence and significance of these symptoms have not been established in this clinical context. OBJECTIVE: To evaluate prospectively the prevalence and associations of EIM of IBD in ulcerative colitis (UC) patients following restorative proctocolectomy (RP) and to compare the findings to those in a control group of familial adenomatous polyposis (FAP) patients who had undergone similar surgery. METHODS: One hundred and twenty-three (97 UC and 26 FAP) consecutive patients with ileal pouches undergoing long-term follow-up underwent an assessment of rheumatological symptoms and signs, similarly of other EIM; each underwent pouch endoscopy and biopsy. RESULTS: Symptoms in the joints were reported in 30 (31%) of UC patients compared to two (8%) FAP patients (P = 0.02). Twenty-four (80%) of the affected patients had a polyarticular arthralgia affecting primarily the knees, and small joints of the hands. Clinical findings and radiological investigations were almost exclusively normal. Most patients had mild symptoms, with only 12 of the 30 reporting interference with daily life. The presence of symptoms in the joints was not associated with a positive family history for IBD or other EIM, the presence of non-rheumatological EIM or the presence of pouchitis. Histological scores of pouch inflammation did not differ between those with and without symptoms of the joints. CONCLUSIONS: A mild polyarticular arthralgia, similar to that associated with active IBD, is common following RP and may commence after surgery. It is not associated with the presence of pouch inflammation.

Adult↗

PubMed2006

One-stage completely laparoscopic restorative proctocolectomy for ulcerative colitis complicated with sigmoid colon cancer--a case report.

Recent advances in laparoscopic surgery have made it possible to perform restorative proctocolectomy (RP) for ulcerative colitis (UC) or familial adenomatous polyposis (FAC). However, most of these procedures are performed as two-stage operations with the creation of diverting ileostomy. Furthermore, they are performed with a small abdominal incision from 4 to 8 cm in length. We describe the first case of ulcerative colitis that underwent a single-stage completely laparoscopic restorative proctocolectomy without an abdominal incision. The patient also underwent lymph node dissection since he had a sigmoid colon cancer. The postoperative course was uneventful and the functional outcome was satisfactory. Considering the improved cosmetic as well as functional results achieved by this procedure, the present technology can be applied for selected patients, especially young UC or FAP patients needing RP who seek for a superior cosmetic result.

Adult↗

PubMed2005

Safety of one-stage restorative proctocolectomy for ulcerative colitis.

PURPOSE: The aim of this study was to compare clinical outcomes in patients with ulcerative colitis who underwent restorative proctocolectomy with and without diverting ileostomy. METHODS: A series of 245 consecutive patients who underwent ileal pouch anal anastomosis with mucosectomy with an ultrasonically activated scalpel (harmonic scalpel) was studied. Of these patients, 92 patients had a diverting ileostomy and 150 selected patients did not. The decision for or against an ileostomy was made at the end of the operation. RESULTS: Twelve patients (8 percent) in the group without ileostomy had pouch-related complications, which necessitated secondary ileostomy in five patients (3.3 percent). Intestinal obstruction developed in 17 patients (11.3 percent) who had no ileostomy and in 12 patients (13.0 percent) who underwent ileostomy. Two of 17 patients who had no ileostomy and 1 of 12 patients with ileostomy required laparotomy with division of adhesions, whereas the remaining patients responded to conservative measures. There were no significant differences in the incidence of postoperative complications after the initial operation between the two groups. In the group with ileostomy, the morbidity rate for ileostomy was 12.1 percent, and that for ileostomy closure was 18.7 percent. The total postoperative complication rate for the group with ileostomy was significant higher than that for the group without ileostomy. CONCLUSION: We conclude that restorative proctocolectomy with mucosectomy by use of an ultrasonically activated scalpel and without diversion is a superior therapeutic choice for selected patients.

Adolescent↗

PubMed1991

Comparison of restorative proctocolectomy with and without covering ileostomy in ulcerative colitis.

The experience of restorative proctocolectomy for ulcerative colitis is reported in 16 consecutive patients with no covering ileostomy (group 2) in comparison with 15 patients with a covering stoma (group 1); in each group a J pouch was constructed. All patients had pre- and postoperative clinical and manometric evaluations of the functional result up to 12 months. There were no deaths or permanent failures. The number of early complications was four in each group. Re-ileostomy was needed in one patient of group 1, and an ileostomy was constructed in three patients of group 2. At 1 year after operation the functional results did not differ between groups 1 and 2 in terms of daily frequency of defaecation (mean 5.6 and 5.4 in 24 h respectively), or in terms of anal basal or maximal squeeze pressures. There was a significant (P less than 0.01) saving in total hospital stay (median 11 days) and in operating theatre time (mean 41 min) in patients with no covering ileostomy. It is concluded that a covering ileostomy may be unnecessary in restorative proctocolectomy, at least in suitable cases with no technical difficulty at the time of operation.

Adolescent↗

PubMed2005

Management and outcome of pouch-vaginal fistulas following restorative proctocolectomy.

PURPOSE: The aim of this study was to assess the short-term and long-term outcomes of surgical repair of patients with pouch-vaginal fistulas after restorative proctocolectomy. METHODS: A descriptive study was undertaken of all patients developing pouch-vaginal fistulas following restorative proctocolectomy between 1978 and 2003 in a single tertiary referral institution. Kaplan-Meier survival analysis was used to evaluate the time to first pouch-vaginal fistula recurrence and pouch-vaginal fistula-free survival at last follow-up. RESULTS: Sixty-eight patients (mean age, 32.2 years; standard deviation, 10.7) were identified with a median follow-up of 5.5 (range, 0.2-25.5) years. The origin of the pouch-vaginal fistulas was the pouch-anal anastomosis in 52 (76.5 percent) patients, pouch body/top in 9 (13.2 percent), or cryptoglandular or other source in 7 (10.3 percent). Associated early complications in patients with pouch-vaginal fistulas included pelvic sepsis in 20 (29 percent) patients, anastomotic separation in 6 (24 percent), anastomotic stricture in 16 (24 percent), small bowel obstruction in 17 (25 percent), hemorrhage in 2 (3 percent), or pouchitis in 12 (18 percent). Surgery was undertaken in 59 (87 percent) patients with 14 (20.6 percent) of them undergoing pouch excision/diversion or seton drainage. Forty-five (66 percent) patients underwent primary repair. First recurrence of pouch-vaginal fistula occurred in 27 of 45 (60 percent) patients with a median pouch-vaginal fistula-free interval of 1.6 years (95 percent confidence interval, 0.6-2.7). Fourteen (51.9 percent) patients with recurrent pouch-vaginal fistulas healed following one or more repeat procedures. The diagnosis of Crohn's disease was made in eight (12 percent) patients, with pouch-vaginal fistulas persisting or recurring in all patients with Crohn's disease within five years of the primary treatment. Median pouch-vaginal fistula-free survival was 1.4 years for patients with Crohn's disease and 8.1 years for patients with ulcerative colitis or familial adenomatous polyposis. The pouch-vaginal fistula-free survival improved with repeated local or abdominal repairs for patients with ulcerative colitis. The overall pouch failure rate for patients with pouch-vaginal fistulas was 35 percent (median pouch survival, 4.2 years). CONCLUSIONS: Pouch-vaginal fistulas can persist and recur indefinitely, even after repeated repairs. Repair in those patients with Crohn's disease uniformly failed within five years from primary repair. Patients with recurrent pouch-vaginal fistulas and ulcerative colitis should be offered salvage surgery because successful closure following initial failure occurs in approximately 50 percent.

Adult↗

PubMed1996

Stenosis of the pouch anal anastomosis following restorative proctocolectomy.

PURPOSE: To compare the incidence of stenosis after hand-sewn and stapled ileoanal anastomosis. Stenosis of the ileoanal anastomosis occurs in 5-16% of patients undergoing a restorative proctocolectomy but the incidence using a stapled technique is unknown. METHODS: Between 1976 and 1990, 266 patients underwent restorative proctocolectomy or proctectomy at one hospital. In two hundred and eighteen the anastomosis was hand sewn and stapled in 48 (single 33; double 15). RESULTS: Stenosis occurred in 31 (14.2%) of the hand-sewn and in 19 (39.6%) of the stapled anastomoses. This difference was highly significant (P < 0.001). Stenosis was not related to the size of the staple head used or to the stapling technique. There was no relationship between the development of stenosis and pelvic sepsis. Twenty six (hand-sewn 16, stapled 10) of the 48 patients with stenosis needed dilatation under general anaesthetic. CONCLUSION: Stapled anastomoses may result in a high incidence of anastomotic stenosis.

Adolescent↗

PubMed2005

Restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis and familial adenomatous polyposis: twenty years follow-up in 174 patients.

BACKGROUND: Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical procedure of choice for patients with ulcerative colitis and familial adenomatous polyposis. OBJECTIVES: To evaluate the long-term functional outcome of patients who underwent this surgical procedure. METHODS: We performed this observational study in 174 consecutive patients: 146 with UC and 28 with FAP. The patients, 91 males and 83 females with a mean age of 34.1+/-10.6 years (range 6-67 years), underwent the procedure between January 1984 and January 2004 (mean follow-up 64.8 months, range 1-240 months). The indications for surgery were intractable disease in 124 patients (71%), dysplasia in 36 (21%), severe bleeding in 8 (5%), and perforation in 6 (3%). RESULTS: A protective ileostomy was performed in 140 patients (96%) with UC and 12 (43%) with FAP. An urgent three-stage procedure was necessary in 14 patients (8.4%). A mucosal proctectomy was performed in 94 (54%), and a double stapling technique in 80 (46%). Mean length of hospital stay was 9.4+/-6.6 days (range 5-34 days, median 8). Complications included pelvic sepsis in 7 patients (4.2%), anastomotic leakage in 8 (4.8%), bowel obstruction in 22 (13.2%), incisional hernia in 12 (7.2%), anastomotic stenosis that usually responded to manual dilatation in 46 (27.6%), pouchitis in 106 (61%), recto-vaginal fistula in 3 (1.8%), retrograde ejaculation in 3 (1.8%), and impotence in 2 (1.2%). There was no mortality in this group of patients. The median number of bowel movements per 24 hours was six in UC patients and five in FAP patients, with at least one bowel movement during the night. Complete daytime and night-time continence was documented in 124 patients (71%). Overall satisfaction was 95%. CONCLUSIONS: Restorative proctocolectomy with ileal pouch-anal anastomosis confers a long-term good quality of life to both UC and FAP patients, and the majority of patients are fully continent with five to six bowel movements per day.

Adenomatous Polyposis Coli↗

PubMed1988

Anal sensation after restorative proctocolectomy for ulcerative colitis.

The hypothesis that anal sensation might be better after restorative proctocolectomy with end-to-end ileoanal anastomosis than after mucosal proctectomy with endo-anal anastomosis was tested in this study. Anal sensation was measured in 14 patients before operation, 16 patients after restorative proctocolectomy with end-to-end anastomosis (RP + EEA) and 13 patients after mucosal proctectomy with endo-anal anastomosis 1 cm above the dentate line (MP + EAA). Threshold electrosensitivity was measured in the upper, mid and lower anal canal by means of a bipolar constant current stimulator probe. The 'recto'-anal inhibitory reflex was tested, and the patients' ability to discriminate between flatus and faeces and to release flatus 'safely' was assessed by interview. In the upper anal canal, threshold sensitivity was significantly greater in patients who had undergone MP + EAA than in patients who had undergone RP + EEA (P less than 0.05). In the mid and lower anal canal, electrosensitivity in the three groups of patients did not differ significantly. Twelve patients (75 per cent) regained the 'recto'-anal reflex after RP + EEA, but after MP + EAA only three patients (23 per cent) did so (P less than 0.02). Thirteen patients after RP + EEA could release flatus safely without fear of faecal leakage, compared with only four after MP + EAA (P less than 0.02). The proportions of patients in these two groups who said they were able to discriminate flatus from faeces did not differ significantly. Anal sensation and discriminatory function are significantly better after end-to-end ileoanal anastomosis than after mucosal proctectomy with endo-anal anastomosis.

Adult↗

PubMed1992

Transitory elevation of serum amylase levels after restorative proctocolectomy.

The incidence of postoperative hyperamylasaemia was evaluated in 70 patients who underwent staged restorative proctocolectomy. On the 14th postoperative day, 27 of 70 patients after total colectomy showed hyperamylasaemia, and the serum amylase returned to normal on the 30th postoperative day. Three out of 37 after ileoanal anastomosis and 8 out of 70 after stoma closure showed elevation of serum amylase postoperatively. Total colectomy might have a possible role in the postoperative increase of serum amylase. None of these patients had any obvious clinical evidence of postoperative pancreatitis. In 7 patients showing significant elevation of serum amylase levels (over 1000 IU), this was due predominantly to the pancreatic isoenzyme. This transitory elevation of serum amylase did not seem to be altered by the administration of therapeutic agents for pancreatitis. These observations suggest that postoperative hyperamylasaemia without clinical evidence of pancreatitis is very common after total colectomy, and that postoperative hyperamylasaemia itself does not necessarily require treatment.

Adenomatous Polyposis Coli↗

PubMed1992

Carcinoma of the rectal pouch following restorative proctocolectomy. Report of a case.

A case of adenocarcinoma developing in the pouch following restorative proctocolectomy is presented. This seems to be the third reported in the literature. The carcinoma developed from the remnants of precancerous rectal mucosa left in the muscular rectal cuff. The patient had been suffering from ulcerative colitis for 17 years prior to the development of the malignancy. He presented with features of subacute intestinal obstruction. Diagnosis was by sigmoidoscopic examination of the pouch and biopsy. He was treated with abdominoperineal resection of the pouch and rectum, followed by chemotherapy.

Adenocarcinoma↗

PubMed1999

Restorative proctocolectomy with ileal pouch-anal anastomosis in 203 patients: the Auckland experience.

BACKGROUND: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become an established operation for patients with ulcerative colitis and familial adenomatous polyposis (FAP). The results of a 15-year experience with IPAA are reported. METHODS: Between September 1982 and June 1997, 203 patients had IPAA surgery. From a review of the charts, data were collected on the surgical procedure, the diagnosis and early and late complications. Pouch function was assessed by means of a postal questionnaire. RESULTS: Of the 201 patients (median age of 32 years; 89 women) with complete records, 122 had J pouches, 65 had W pouches and 14 S pouches were constructed. The pre-operative diagnosis in 88% was ulcerative colitis and in 10% it was FAP. During a median follow-up time of 6.1 years the diagnoses were changed for 8% of the patients; in 4% the diagnosis was changed to Crohn's disease. The overall mortality was 1.5% (early = 2, late = 1). The overall morbidity was 62% (early = 17%, late = 52%). The pouch was removed or was non-functional in 9%. All patients with a final diagnosis of Crohn's disease have had their pouch excised. The median stool frequency was 4.0 (range 1.3-8.7) during the day, and 0.7 (range 0-2.1) during the night. The fewer night-time stools (J = 1.0+/-0.6; W = 0.4+/-0.5 P < 0.0001) and the reduced requirement of the W-pouch patients for anti-diarrhoeals (P = 0.004) were offset by the need for two W-pouch patients to pass a catheter to empty their pouches. CONCLUSIONS: The type of patients who present for IPAA surgery and the outcomes observed in this series of Auckland patients are similar to those reported from major centres elsewhere.

Adenomatous Polyposis Coli↗

PubMed1997

[Restorative proctocolectomy in treatment of ulcerative colitis and familial polyposis].

The results of surgical management (restorative proctocolectomy) in 15 patients operated on for familial polyposis and ulcerative colitis were presented. The comparison of ileo-anal, hand-sewn anastomosis with endorectal mucosectomy and double-stapled ileo-rectal anastomosis indicates both methods equally useful in surgical practice. In all patients J-pouch was created. The choice of anastomosis should be carefully considered before operation in every patient, but sometimes changed intraoperatively.

Adenomatous Polyposis Coli↗

PubMed1995

Harry E. Bacon Oration. Comparison of the functional results of restorative proctocolectomy for ulcerative colitis between the J and W configuration ileal pouches with sutured ileoanal anastomosis.

PURPOSE: This study was designed to compare function of patients who had undergone reconstruction following proctocolectomy for ulcerative colitis using the J or W configuration ileoanal pouch. METHODS: Of 126 patients who underwent restorative proctocolectomy between January 1981 and March 1993, 101 had surgery for ulcerative colitis. Eighty-seven of these patients were available for review by personal or postal interview. All operative procedures were performed by one surgeon. The group comprised 35 W-pouches and 52 J-pouches. RESULTS: More patients with a J-pouch had a stool frequency of greater than 8 per 24 hours (P = 0.044), and they were also more likely to use a perineal pad (P = 0.019). No difference in the rates of nocturnal stool frequency, fecal incontinence, or use of constipating agents between the two pouch designs was found. Significantly more patients with a J-pouch have had episodes of pouchitis (P = 0.001). Of the total patient group 91.9 percent felt that restorative proctocolectomy had improved their quality of life. CONCLUSION: Minor differences in the function of the W configuration ileoanal pouch and the J configuration ileoanal pouch are demonstrated in this study.

Adult↗