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PubMed1994

Postoperative electrolyte and mineral balance after restorative proctocolectomy with ileoanal reservoir.

Postoperative electrolyte and mineral balance was studied in nine patients with ulcerative colitis who underwent restorative proctocolectomy with ileoanal reservoir (J-pouch). The study was carried out during the first seven days of bowel function after construction of the reservoir and temporary ileostomy, and again after the ileostomy was closed and bowel continuity re-established. Stool volume and intestinal sodium excretion were reduced by respectively 40 and 45% after ileostomy was closed (p < 0.05), but potassium excretion was unchanged. The concentration of sodium was higher in ileostomy effluents, whereas the concentration of potassium was higher in stools after the ileostomy was closed (p < 0.05). Significant changes in blood and urinary electrolytes or minerals were not recorded. It is concluded that a major reduction in stool volume and intestinal excretion of sodium is already present in the early postoperative period after bowel continuity has been re-established.

Adult↗

PubMedDate not supplied

Restorative proctocolectomy: the Irish experience. Irish Association of Coloproctology.

Between January 1982 and March 1990, 106 patients underwent restorative proctocolectomy in eight separate surgical departments. The indication for operation was ulcerative colitis in 86%, familial adenomatous polyposis in 12% and megacolon in 2%. The age at operation was 33 +/- 2 years (mean +/- sem) (range 15-55 years). There were no perioperative deaths. The principal causes of post-operative morbidity were intra-abdominal sepsis (15%), anastomotic stricture (10%) and intestinal obstruction (8%). Intestinal continuity has been restored in 99 patients. All were grossly continent, but 32% experienced occasional soiling. The mean stool frequency was 5/day and 1/night. The overall failure rate was 6%. Eighty-nine percent of patients were happy with the outcome. We conclude that restorative proctocolectomy is safe and provides acceptable functional results. It should be the operation of choice in most patients with ulcerative colitis or familial adenomatous polyposis.

Adolescent↗

PubMed2003

Clinical results after restorative proctocolectomy without diverting ileostomy for ulcerative colitis.

BACKGROUND AND AIMS: This study evaluated the postoperative complications and clinical results of restorative proctocolectomy without diverting ileostomy for ulcerative colitis. PATIENTS AND METHODS: One hundred selected patients had a hand-sewn ileal J-pouch anal anastomosis with mucosectomy using an ultrasonically activated scalpel. RESULTS: Three patients with pouch-related complications who needed diverting ileostomy. Five patients showed intestinal obstruction; two of the five needed relaparotomy and division of adhesions. The median number of bowel movements per 24 h was 6.5 (2-13) at 3 months and 5 (3-10) at 12 months. The corresponding nightly frequencies were 0 (0-5) at 3 months and 0 (0-3) at 12 months. After 3 months 82% of patients had no soiling during the daytime, and 45% were fully continent day and night. After 3 months 89% had recovered the ability to distinguish flatus from feces. CONCLUSION: Ileal pouch anal anastomosis can be performed safely without diverting ileostomy using an ultrasonically activated scalpel. The postoperative functional result was stabilized 3 months after the operation.

Adolescent↗

PubMed2000

Comparison of loop versus end ileostomy for fecal diversion after restorative proctocolectomy for ulcerative colitis.

BACKGROUND: The goal of this study was to compare the benefits versus complications of temporary loop ileostomies and end ileostomies in a consecutive series of patients undergoing colectomy and ileal pouch-anal anastomosis for ulcerative colitis. STUDY DESIGN: A retrospective review was performed of all patients undergoing restorative proctocolectomy with diverting ileostomy for ulcerative colitis at the UCLA Medical Center during a 4-year period. An end ileostomy (EI) was used for 38 patients and a loop ileostomy (LI) for 39. All patients had a J pouch, with all EI patients having a hand-sewn ileoanal anastomosis, and 33 LI patients having a double-stapled anal anastomosis. EI closure was performed through a laparotomy, and LI closure was performed through a periileostomy incision. RESULTS: The mean operative time for EI closure was 157 minutes, and for LI closure was 103 minutes. The wound infection rate after EI closure was 5.3% and after LI was 10.3%. For EI patients, 2 of 38 patients required reoperation, compared with 5 of 39 for LI. The mean hospital stay after EI closure was 6.7 days, and after LI closure was 7.1 days. Peristomal skin irritation was more severe, more prolonged, and occurred in more than twice as many LI as EI patients. Home ostomy nurse care was necessary for a mean of two visits for EI patients and five visits for LI patients. The cost ofostomy supplies and care was more than double for LI patients compared with those with EI. Patient satisfaction and ability to resume physical and social activities early after ileostomy construction were much more favorable for EI than LI patients. CONCLUSIONS: The benefit of shorter operating time for LI closure compared with EI closure is often outweighed by the complications and costs of LI stomal care and patient dissatisfaction. EI should be considered more frequently for temporary ileal diversion after restorative proctocolectomy.

Adolescent↗

PubMed1999

Ursodeoxycholic acid has no influence on function after restorative proctocolectomy in ulcerative colitis.

BACKGROUND: Poor pouch function is associated with impaired bile acid absorption and increased faecal loss of bile acids. Bile acid replacement therapy might therefore be of clinical benefit, provided that diarrhoea is not aggravated by therapy. AIM: To investigate the role of exogenous bile acid therapy in patients with poor pouch function after restorative proctocolectomy for ulcerative colitis. PATIENTS AND METHODS: Twenty ulcerative colitis patients with poor pouch function (score > 4 on a 12-point score) were recruited for inclusion to a prospective, randomized, double-blind crossover, placebo-controlled trial of ursodeoxycholic acid (10 mg/kg per day in two divided doses for 1 month). RESULTS: A total of 16 patients completed the study. There was no significant difference in the functional score or bowel frequency following treatment irrespective of whether the active treatment was given before or after placebo. CONCLUSIONS: We conclude that ursodeoxycholic acid given over 4 weeks had no influence on functional score or bowel frequency after restorative proctocolectomy for U.C.

Adult↗

PubMed2002

Restorative proctocolectomy with ileal reservoir.

OBJECTIVE: Restoractive proctocolectomy with ileal reservoir is a procedure that eliminates mucosal disease of the colon and rectum yet it preserves fecal continence. It has become the operation of choice for most patients with chronic ulcerative colitis and familial adenomatous polyposis. METHODS: The study was carried out at Baghdad Teaching Hospital, Medical City, Baghdad, Iraq, during the period January 1988 through to January 2001, we carried out 30 cases of restoractive proctocolectomy with ileal reservoir. At the beginning we used the S pouch (3 cases), then the J pouch (8 cases), finally we shifted to the extended J pouch (19 cases) with improved results. RESULTS: Our surgical technique and the pre-operative and post-operative care improved, with more cases of restorative proctocolectomy with ileal reservoir carried out in our center. This is associated with a good progress in the functional results and a decrease in the early and late complications of the procedure. CONCLUSION: Restorative proctocolectomy with ileal reservoir is a major surgical procedure with many early and late complications, but if it is carried out in expert hands with careful selection of the patients it will give good results.

Adenomatous Polyposis Coli↗

PubMed1993

Prospective assessment of functional results after ileal J pouch-anal restorative proctocolectomy.

OBJECTIVE: To document the functional results of 50 consecutive patients who underwent hand-sewn ileal J pouch-anal restorative proctocolectomy for ulcerative colitis between 1988 and 1991 (mean follow-up, 18.1 months; range, 6 to 48 months). DESIGN: Patients recorded their observations daily over 1 week. The patients completed these weekly diaries every 3 months for the first year and then at 18, 24, 36, and 48 months after ileostomy closure. STUDY PARTICIPANTS: Fifty patients (mean age, 31 years; 24 males). SETTING: The University of Chicago (Ill). RESULTS: Stool frequency at 3, 6, 12, and 24 months was 6.3 +/- 2.1, 5.5 +/- 2.4, and 5.1 +/- 1.9, and 5.9 +/- 1.6 per day, respectively, without urgency. Fifty-four percent were perfectly continent; 18% had occasional spotting (one or two leaks per week); 12% had minor leakage (three to seven per week); and 16% had major leakage (more than seven per week). In these three groups, loss of solid feces never occurred in 84%, 88%, and 65% of patients, respectively. Females had more severe incontinence than males, but continence improved over time for both sexes. Twenty-two percent of female patients developed dyspareunia; no males developed impotence, but 19% had retrograde ejaculation. The probability of experiencing pouchitis increased with time from 15% at 6 months to 40% at 12 months, and 50% after 24 months. CONCLUSIONS: These results represent an accurate assessment of patient function after ileal J pouch-anal anastomosis. We encourage the use of a prospective, patient-completed protocol to obtain a realistic assessment of functional results.

Adolescent↗

PubMed1998

The implications of acute pouchitis on the long-term functional results after restorative proctocolectomy.

A prospective study was conducted to determine the implications of acute pouchitis on the long-term functional results of restorative proctocolectomy with J-pouch ileoanal anastomosis (IPAA). Between July 1988 and June 1996, 137 consecutive patients underwent IPAA for treatment of ulcerative colitis. 127 patients (93%) have been available for follow-up. All patients completed diaries detailing bowel habits over a 7-day period at 3, 6, 9, 12, 18, 24 months, and yearly after reestablishment of intestinal continuity. Diaries were completed only during time periods in which patients were not suffering from acute symptomatic pouchitis. Patients with chronic pouchitis (n = 7) were excluded from this study leaving 120 patients for analysis. Fifty patients suffered at least one episode of pouchitis (Pouchitis Group). Seventy patients never had pouchitis (No Pouchitis Group). Patients with a history of pouchitis having significantly more bowel movements per day were more likely to ever have minor incontinence (75% vs. 45%, p < 0.005) or major incontinence (37% vs. 17%, p < 0.02). The stools of Pouchitis Group were less likely to be formed (24% vs. 31%, p < 0.001). Pouchitis Group patients also were more likely to wear a protective pad during the day (21% vs. 7% p < 0.04) or during the night (40% vs. 13%, p < 0.001). Even in the absence of clinically active pouchitis, patients who have suffered at least one episode of pouchitis have a poorer long-term functional result after IPAA. The results of this study suggest that ileal pouchitis may represent a chronic condition that displays episodic symptomatic exacerbations.

Acute Disease↗

PubMed1996

Does eversion of the anorectum during restorative proctocolectomy influence functional outcome?

PURPOSE: The aim of this study was to determine the effect of eversion of the anorectum during restorative proctocolectomy (RP) for ulcerative colitis on functional outcome. METHODS: One hundred seventeen patients underwent RP with stapled end-to-end ileal pouch-anal anastomosis (EEA), without resection of the anal mucosa. Sixty-four underwent EEA with eversion of the anorectum, and 53 underwent EEA without eversion. Each patient underwent paired studies of anorectal function before and a median of 12 months after RP. RESULTS: One year after RP, median (interquartile range) maximum resting pressure was 69 (range, 51-88) cmH2O in those patients who underwent eversion vs. 80 (range, 64-90) cmH2O in patients without eversion (P < 0.04). Threshold sensation in the upper, middle, and lower thirds of the anal canal were 9.1, 7.4, and 6.8 mA after eversion vs. 6.9, 4.9, and 3.8 mA without eversion (P = 0.003, P < 0.001, P < 0.001, respectively). Before operation, all patients had a rectoanal inhibitory reflex; however, after RP, 54 of 64 patients in the eversion group and 50 of 53 patients with a stapled EEA without eversion had an inhibitory reflex (P = not significant). Leakage of mucus was experienced by 11 patients who underwent eversion, compared with 9 patients without eversion. Fifty-six of 64 patients with eversion could defer defecation for more than 30 min compared with 43 of 53 patients without eversion. Twenty-two of 64 patients in the eversion group retained perfect discrimination between flatus and feces compared with 38 of 54 without eversion (P < 0.001). Level of the anastomosis was 1 (range, 0.5-3) cm above dentate line after eversion compared with 1.5 (range, 0-6) cm without eversion. CONCLUSION: Clinical outcome after RP with eversion was not as good as outcome after stapled EEA without eversion. Such a conclusion requires confirmation in a prospective control trial.

Adult↗

PubMed2006

Postoperative liver enzyme abnormalities are related to staged restorative proctocolectomy.

BACKGROUND: Transient homeostatic derangements are found after major abdominal and pelvic surgery. We observed elevated liver function tests (LFTs) after restorative proctocolectomy (RPC). This study was undertaken to determine the etiology and implications of elevated LFTs before RPC and postoperatively. METHODS: One hundred and thirty-four RPC-patients were prospectively evaluated for LFT abnormalities. Patients were assigned to two groups: hand-sewn ileal-reservoir after mucosoproctocolectomy (n=83) or stapled anastomosis (n=9), both with loop ileostomy and stapled anastomosis without loop ileostomy (n=42). Serum alanine-aminotransferase (ALAT) and alkaline phosphatases (ALP) were assessed preoperatively, 1-10 weeks postoperatively before loop ileostomy closure and 1-10 weeks after ileostomy closure. These findings were correlated with anesthesia time, transfused blood volume, perioperatively administered drugs, and length of the diverted bowel while having a loop ileostomy. RESULTS: A large number of patients showed initial elevated serum ALAT and ALP levels, suggesting liver cell damage. There was a substantial and significant increase in ALAT and ALP in the first postoperative week. The values normalized within 2 weeks for the group without loop ileostomy, but not until after loop ileostomy closure in first group. A significant correlation as to length of diverted bowel (<0.05) while having a loop ileostomy was noted. When the length of diverted bowel was more than 105 cm, liver enzymes were higher than baseline levels (p<0.05) until after closure. CONCLUSIONS: Patients may develop elevated LFTs after RPC; however, its etiology and significance remains unclear. A loop ileostomy with RPC seemed to delay the normalization. Consideration of further diagnostic imaging may be indicated to exclude other liver pathology such as sclerosing cholangitis.

Adolescent↗

PubMed2000

Long-term clinical outcome and anemia after restorative proctocolectomy for ulcerative colitis.

BACKGROUND: The purpose of this study was to evaluate long-term outcome and hematologic data after restorative proctocolectomy (RPC) and mucosectomy with hand-sewn J-pouch-anal anastomosis for ulcerative colitis (UC). METHODS: Forty-eight (75%) out of 64 consecutive patients operated on during the period 1985-1990 participated in a long-term follow-up in 1998. Study visits involved an interview according to a 23-item functional questionnaire, pouch endoscopy and blood samples. Pre- and postoperative data on these patients were reviewed at our own database covering all operations performed for UC at our institute. RESULTS: Functional disturbances were common and unchanged during long-term follow-up. Minor incontinence occurred in 37.5% and outlet difficulties in 10.5% of patients. Bowel obstruction occurred in 16.7% and usually needed operative treatment. Twenty-four (50.0%) patients had had at least one episode of pouchitis and chronic or severe pouchitis occurred in 18 (37.5%) cases. Males seem to have chronic pouchitis more often. Ten (20.8%) patients had anemia during follow-up. Recurrent bleeding from the pelvic pouch and chronic pouchitis exposed to the anemia. CONCLUSIONS: Minor morbidity is common after RPC. Pouchitis occurred in half of our patients during long-term follow-up. There may be a risk of anemia with chronic pouchitis and bleeding from the pelvic pouch mucosa.

Adult↗

PubMed2002

Filling sensations after restorative proctocolectomy.

OBJECTIVE: In order to improve insights in rectal filling sensation, we studied pouch filling sensations after ileal J pouch-anal anastomosis (IPAA) before and after re-establishment of bowel continuity. METHODS: Anal manometry and a pouch filling sensation test were performed before as well as 1 and 6 weeks after closure of the loop ileostomy in 17 patients who had undergone restorative proctocolectomy with stapled (8 patients) or manual pouch-anal anastomosis (9 patients). The results were compared with those of 12 control subjects. RESULTS: Before ileostomy closure, pouch pressure necessary for inducing the respective sensation thresholds was higher than in controls; the difference was significant for constant and urge sensation. The volumes for urge and maximum tolerable sensation level were significantly lower, with reduced pouch compliance. After stoma closure, pressure and volume thresholds at all sensation levels became completely comparable with control data. No relevant differences were observed between stapled and manual ileal pouch-anal anastomoses. CONCLUSIONS: All levels of filling sensation levels are preserved after restorative proctocolectomy and their parameters are comparable with those of normal rectal filling sensation. Diversion of an ileal J pouch results in resetting of filling sensation thresholds towards lower volume and higher pressure values, but all sensation thresholds normalize within 6 weeks after stoma closure. These data document that neither the rectum, nor the mucosa of the anorectal junction and upper part of the anal canal are involved in filling and urge sensation.

Adult↗

PubMedDate not supplied

[The mucosal electrosensitivity of the anal canal following restorative proctocolectomy for ulcerative colitis].

The aim of this study was to investigate the mucosal electrosensitivity of the anus in 23 patients following restorative proctocolectomy for ulcerative colitis. In 16 cases mechanical anastomosis was performed 2 cm above the pectineal line conserving the transitional anal mucosa and in 7 cases distal rectal mucosectomy and manual anastomosis was performed to the pectineal line. In these patients and in those of the control group of 21 patients without previous anorectal disease, the threshold of sensitivity of the lower, middle and upper anus segment was determined. A clinical questionnaire was made in the patients with ileoanal reservoir to evaluate the existence of alterations in continence, and in the capacity to discriminate between gases and stools. The sensitivity thresholds obtained were significantly higher than those in the control group. A significantly greater sensitivity threshold (p = 0.01) was found in the upper anus segment in patients with mucosectomy (median 18.5 mA) with respect to the patients with mechanical anastomosis (median 11 mA). A significantly greater threshold was also observed (p = 0.03) globally in the patients with some alteration in continence (median 15 mA; 57.1% mucosectomy and 18.8% mechanical anastomosis) with respect to completely continent patients (median 11 mA). The results demonstrate the importance of conserving the transitional anal mucosa during surgery with the aim of improving the functional results during the follow of the functioning ileoanal reservoir.

Adult↗

PubMed1993

Restorative proctocolectomy with end to end pouch-anal anastomosis in patients over the age of fifty.

This study was to examine whether 'fit' patients over the age of 50 who require elective surgery for ulcerative colitis are suitable candidates for restorative proctocolectomy, providing that they are continent before operation and that the anal sphincter is preserved in its entirety without stripping of the mucosa or endoanal anastomosis. Between 1986 and 1991, 18 patients 50 to 66 years old (median 55 years: nine men) underwent restorative proctocolectomy with end to end ileoanal anastomosis without mucosal stripping (12 quadruplicated (W), four duplicated (J), two no reservoir). The results were compared 12 (range three to 24) months later with those of 18 matched patients who were less than 50 years of age (median 34 years). In patients over 50, median resting anal pressure was 88 (range 44-131) cm water before and 80 (47-138) cm water after the operation (NS). In patients under 50, median resting anal pressure was 76 (51-128) cm water before and 77 (36-137) cm water after operation (NS). Resting anal pressure in older patients did not differ significantly from that in younger patients either before or after the operation. Both sensory and reflex anal functions were preserved as well after operation in the older patients as in the younger ones. The clinical results in patients over 50 were slightly inferior to the results for the younger patients, but the difference was small and not significant. Hence age alone is not a contraindication to restorative surgery provided that the anal sphincter is preserved in its entirety.

Adolescent↗

PubMed2006

Long-term results of abdominal salvage surgery following restorative proctocolectomy.

BACKGROUND: This study evaluated outcomes of patients who underwent abdominal salvage ileal pouch redo surgery and identified factors associated with pouch failure following restorative proctocolectomy. METHODS: Data on patients who underwent abdominal salvage surgery in a tertiary referral centre between 1985 and 2003 were collected. Outcomes studied included failure of salvage and bowel function of patients with an intact intestine. RESULTS: One hundred and twelve patients underwent 117 pouch salvage procedures for ulcerative colitis (86), indeterminate colitis/ulcerative colitis (eight), indeterminate colitis/Crohn's disease (three), familial adenomatous polyposis (ten) and other conditions (five). The most common indications for pouch salvage were intra-abdominal sepsis (45 patients), anastomotic stricture (13) and retained rectal stump (35). Median follow-up was 46 (range 1-147) months. Twenty-four patients (21.4 per cent) experienced pouch failure, the incidence of which increased with time. The pouch failed in all patients with Crohn's disease. Successful salvage at 5 years was significantly associated with non-septic (85 per cent) rather than septic (61 per cent) indications (P = 0.016). Frequency of night-time defaecation and faecal urgency improved after salvage surgery (P = 0.036 and P = 0.016 respectively at 5-year follow-up; n = 32). CONCLUSION: Abdominal salvage surgery was associated with a failure rate of 21.4 per cent. A successful outcome was less likely when the procedure was carried out for septic compared with non-septic indications. The rate of pouch failure increased with length of follow-up.

Adolescent↗

PubMed1997

Cancer in the anal canal (transitional zone) after restorative proctocolectomy with stapled ileal pouch-anal anastomosis.

The first case of an adenocarcinoma developing in the retained anal canal mucosa (transitional zone) after restorative proctocolectomy with a stapled ileal pouch anal anastomosis is presented. The cancer was detected during routine follow-up 16 months after pouch formation for long standing ulcerative colitis, complicated by a cancer in the upper rectum. The patient was treated with an abdominoperineal excision of the ileal pouch and anus.

Adenocarcinoma↗

PubMed2001

Mouth to pouch transit after restorative proctocolectomy: hydrogen breath analysis correlates with scintigraphy.

OBJECTIVES: Fast intestinal transit may be responsible for slow adaptation and unacceptable steady-state function after restorative proctocolectomy. Investigation of GI transit time may be valuable in such a setting. We hypothesized that postprandial hydrogen breath tests may yield transit data that correlate with technetium-labeled meal scintigrams. METHODS: This study compared intestinal transit after a lactulose and bean meal via the breath hydrogen and scintigraphy methods in 21 ileoanal pouch subjects. The meal consisted of baked beans (425 g), 30 ml (20 g) lactulose syrup, 1 mCi 99mtechnetium sulfur colloid in finely chopped liver and 170 ml tap water. The meal contained 120 Kcal (70% carbohydrate, 18% protein and 12% fat). RESULTS: Of 21 pouch subjects, 11 (53%) had breath tests and scintigraphy transit studies that differed by 5-21 min. Three of 21 (14%) scintigraphy mouth to pouch transit times were faster than breath test transits by 43-107 min. Seven of 21 (33%) subjects did not have breath test peaks >10 ppm. Mouth to pouch transit for breath hydrogen (104+/-16 min) and scintigraphy (98+/-7 min) tests had significant correlation (r = 0.96, p < 0.0001) among subjects with alveolar hydrogen peaks and accurate scintigrams (n = 11). Scintigrams were five times more expensive than breath tests. CONCLUSIONS: A peaking hydrogen breath test provides an alternative to scintigraphy for estimating intestinal transit after ileoanal pouch.

Adult↗

PubMedDate not supplied

[Aspects of the complications after restorative proctocolectomy in the treatment of ulcerative colitis. Review of the literature and personal experience].

PURPOSE: Analysis of complications and causes of failure after stapled restorative proctocolectomy with ileal J pouchanal anastomosis in patients with ulcerative colitis is presented. PATIENTS AND METHODS: The procedure was performed in 28 patients, 19 males (68%) and 9 females (32%); diverting ileostomy was always performed. RESULTS: There was no perioperative mortality. The overall morbidity rate was 31%. Six patients (21%) had pelvic abscess, 2 (7%) pelvic hematoma, 4 patients (14%) presented ileo-anal anastomotic stricture, 1 patient (3.6%) had pouch-vaginal fistula, three patients (11%) presented intestinal obstruction and 7 (25%) pouchitis. Reoperation was necessary in patients with small bowel obstruction and with pouch-vaginal fistula. Septic complications and pouchitis were resolved with medical treatment. Stenosis of the anastomosis required anal dilation. No patient underwent pouch excision for pouch failure. CONCLUSION: The main significant complications of ileal pouch-anal anastomosis for ulcerative colitis were pelvic sepsis, intestinal obstruction and pouchitis. Our results suggest that the use of stapling technique is safer and has fewer early septic complications and sepsis-related pouch removals. Success in ileo-anal construction increases with experience. The selection of patients with exclusion of Crohn disease, a correct surgical timing, a carefully technique, a delayed ileostomy closure and a low pre and postoperative regimen of steroids are important factors of success.

Adult↗