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PubMed2002

Restorative proctocolectomy: one surgeon's experience of a now routine procedure in a district general hospital.

Restorative proctocolectomy is now the operation of choice for the definitive management of ulcerative colitis and familial adenomatous polyposis coli. The aim of this review is to evaluate clinical and functional results of the first fifty patients treated with restorative proctocolectomy over a period of seven years. A total of 50 patients (28 males, 22 females) underwent restorative proctocolectomy over a period of seven years in our district general hospital. A retrospective analysis of hospital notes was undertaken and supplemented with a patient questionnaire. Forty-three patients had ulcerative colitis and seven had familial adenomatous polyposis coli. Two pouch designs were used, a four limbed "pear pouch" (94%) and a two limb "J" pouch (6%). The majority (98%) of patients had a stapled ileal pouch-anal anastomosis and a similar number had a defunctioning ileostomy. There was no mortality. Early complications (within 30 days of operation) occurred in 18(36%) patients. Late complications were seen in 22 (44%) patients. The median number of daily bowel movements was four (range 1-10). Pouchitis was seen in ten patients (20%). Restorative proctocolectomy is a safe procedure for patients with ulcerative colitis and familial adenomatous polyposis coli. Although total morbidity is appreciable, functional results are generally good and patient satisfaction is high.

Adenomatous Polyposis Coli↗

PubMed2003

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

PURPOSE: The purpose of the study was to evaluate the outcome of surgical management of pouch-vaginal fistulas in females who had undergone restorative proctocolectomy. METHODS: This study was designed as a retrospective chart review of females treated for pouch-vaginal fistulas from 1983 to 2000. All patients were followed up using our prospective pouch registry, with additional data collected by interview or mailed questionnaire. RESULTS: Sixty females were identified (mean age, 33.3 +/- 1.3 years), of whom 33 had their initial restorative proctocolectomy done at our institution. Preoperative diagnosis was ulcerative colitis (88 percent), indeterminate colitis (10 percent), and familial adenomatous polyposis (2 percent). Average time to pouch-vaginal fistula following restorative proctocolectomy was 21 months (range, 1-132 months). Postoperative pelvic sepsis had occurred in 17 (28 percent) patients. Primary treatment modalities included the following: local repairs (n = 46, 77 percent), the majority of which were ileal advancement flaps; redo restorative proctocolectomy (n = 6, 10 percent); and pouch excision (n = 5, 8 percent). Initial healing was achieved in 20 patients. An additional 11 patients with recurrences healed after repeat procedures. The overall healing rate was 52 percent at 49.4 +/- 3.8 months follow-up. Pouch failure was the eventual outcome in 13 (22 percent) patients and 16 (27 percent) patients had persistent pouch-vaginal fistula. A delayed diagnosis of Crohn's disease was made in 24 patients. Crohn's disease patients had lower success rates following ileal advancement flaps compared with the non-Crohn's group (25 vs. 48 percent, respectively), much lower overall healing rates of their pouch-vaginal fistulas (17 vs. 75 percent, respectively), and a higher incidence of pouch failure (33 vs. 14 percent, respectively). CONCLUSION: Pouch-vaginal fistulas are a difficult problem in females following restorative proctocolectomy. However, local repair can be successful with good functional outcomes. Redo restorative proctocolectomy may also achieve healing if local repairs are not possible or have failed. A delayed diagnosis of Crohn's disease results in worse treatment outcome and higher pouch failure rates.

Adenomatous Polyposis Coli↗

PubMed2001

Pouchitis following restorative proctocolectomy for ulcerative colitis: incidence and therapeutic outcome.

BACKGROUND: Pouchitis is a significant sequel of restorative proctocolectomy. This study was undertaken to document the incidence of pouchitis at the Edinburgh Royal Infirmary and to assess outcome of treatment with metronidazole. METHODS: Patients who developed pouchitis following restorative proctocolectomy for ulcerative colitis form the basis of this study. Pouchitis was suspected if patients developed diarrhoea with or without blood, mucus or pus. Diagnosis was confirmed with pouch endoscopy and biopsy. RESULTS: From 1990 to 1999 (10 years) 139 patients underwent restorative proctocolectomy and ileo-anal pouch anastomosis (135 J pouches and 4 W pouches). Their median age was 35 years (range 13-74). There were 68 females and 71 males. The indication for operation was failed medical treatment in 104 patients and toxic megacolon in 35. Forty-seven patients (34%) developed pouchitis (21 females and 26 males). Symptoms were diarrhoea (35), diarrhoea, mucus and pus (5) and diarrhoea and blood (7). Symptoms of pouchitis started at an average of 33.51 + 29.2 months (range 2-102, median 18). All patients were treated with metronidazole for a minimum of one month. Thirty-six patients (77%) resolved on metronidazole alone. Nine patients (19%) went on to develop chronicity and were managed by long-term metronidazole (and/or ciprofloxacin). A further 2 patients (4%) had treatment resistant pouchitis and required pouch excision. CONCLUSION: Pouchitis is common following restorative proctocolectomy for ulcerative colitis. Treatment with metronidazole is associated with improvement in the majority of cases. In patients with chronic pouchitis maintenance of remission is possible with antibiotics. A high index of suspicion is advocated in patients who develop severe diarrhoea following this procedure.

Adolescent↗

PubMed2005

Restorative proctocolectomy for familial adenomatous polyposis coexisting with colorectal cancer.

The aim of this study was to assess whether restorative proctocolectomy was suitable as an initial procedure for selected familial adenomatous polyposis patients with coexisting colorectal cancer. Six malignancy patients who underwent restorative proctocolectomy for familial adenomatous polyposis were reviewed. At the time of restorative proctocolectomy, cancer was not suspected in four patients. The two remaining familial adenomatous polyposis patients had a known associated colorectal cancer. Operative procedures, pathological findings, complications and long-term follow-up were evaluated. All patients were Stage I-II cancers. There was no mortality or pouch failure. No evidence of tumor recurrence was found and all the patients are still alive and disease-free in follow-up (mean 28 months). As an initial procedure, restorative proctocolectomy for patients with familial adenomatous polyposis with coexisting Stage I-II colorectal cancer seems to be a dependable procedure.

Adenomatous Polyposis Coli↗

PubMed2005

Syndrome of duodenal compression by the superior mesenteric artery following restorative proctocolectomy: a case report and review of literature.

CONTEXT: Restorative proctocolectomy with anastomosis of an ileal pouch to the anal canal is a new and rare cause for triggering the syndrome of duodenal compression by the superior mesenteric artery. Restorative proctocolectomy requires assessment of the position of the duodenum in relation to aortomesenteric constriction to avoid the occurrence of duodenal compression by the superior mesenteric artery. CASE REPORT: The authors report on a case of this syndrome in a patient with familial adenomatous polyposis and review the literature on the etiopathogenesis, diagnosis, treatment and prevention of this unusual entity.

Adenomatous Polyposis Coli↗

PubMed2005

Implications of pouchitis on the functional results following stapled restorative proctocolectomy.

PURPOSE: Pouchitis is the most frequent long-term complication of restorative proctocolectomy; its long-term consequences are inadequately described. This prospective study evaluates the effect of pouchitis on the functional results, general health perception, and patient satisfaction. METHODS: A total of 100 consecutive patients who underwent stapled restorative proctocolectomy for ulcerative colitis were divided into three groups: no pouchitis, acute pouch-itis and chronic pouchitis. Functional results, general health perception, and satisfaction of each group at the latest review were compared only when patients were not symptomatic of active pouchitis. RESULTS: Pouchitis occurred in 33 patients (17 acute and 16 chronic). There were no significant differences in the long-term functional results between the no pouchitis and acute pouchitis groups. Patients who experienced chronic pouchitis had a significant increase in bowel movements, looseness of stools, urgency, nocturnal seepage, perianal excoriation, and dietary restrictions (P < 0.05). They also had a worse perception of their general health (P < 0.05). Previous chronic pouchitis had no effect on continence, daytime soilage, or gas-feces discrimination. Most patients were satisfied, despite pouchitis, and would recommend the operation to someone else with ulcerative colitis. CONCLUSIONS: Acute pouchitis is easily treated and results in minimal functional consequences. Even in the absence of clinically active pouchitis, patients who had suffered from chronic pouchitis had poorer functional results and general health perception. This may overshadow the benefits of restorative proctocolectomy. This finding suggests that acute and chronic pouchitis are distinct disease entities and chronic pouchitis may represent a persistent condition that displays episodic symptomatic exacerbation.

Acute Disease↗

PubMed1999

Hydronephrosis: unrecognized complication following restorative proctocolectomy with ileal pouch-anal anastomosis.

Restorative proctocolectomy with ileal pouch-anal anastamosis (IPAA) is the operation of choice to avoid permanent ileostomy in the surgical management of patients with ulcerative colitis and familial adenomatous polyposis coli. IPAA with two loops of small intestine (J-pouch) is the most common configuration. Mortality rates are low, and despite significant morbidity patient satisfaction remains high. Functional results are good in most cases. We present two cases of hydronephrosis following IPAA. Loin pain was the presenting symptom in both cases, with one patient developing impaired renal function. Hydronephrosis has not been reported following IPAA, but with other forms of pelvic and retroperitoneal surgery it is believed to remain largely asymptomatic. We discuss the etiology of this previously unrecognized complication and suggest that it may be more prevalent following IPAA than is realized.

Abdominal Pain↗

PubMed1999

Pouch-sacral fistula three years after restorative proctocolectomy for ulcerative colitis.

Fistula formation after restorative proctocolectomy poses a challenge to the surgeon and sometimes can lead to the excision of the pouch. A 21-year-old female patient developed an ileal J-pouch-sacral fistula with abscess and osteomyelitis of the sacrum, more than three years after the pouch construction for ulcerative colitis. Two months prior to this event, the patient had a single and transient episode of pouchitis. The role of pouchitis in the aetiopathogenesis of the fistula is unclear. To our knowledge, the late development of such a fistula has not been reported previously.

Abscess↗

PubMedDate not supplied

[Clinical and functional results after restorative proctocolectomy with ileal J reservoir in the treatment of ulcerative colitis].

PURPOSE: Restorative proctocolectomy is the procedure of choice in the treatment of ulcerative colitis. The operation is successful in removing all diseased mucosa while preserving a normal bowel function and a good quality of life for the patient. In this article are presented the clinical and functional results obtained in 28 patients, 19 males (68%) and 9 females (32%) after stapled restorative proctocolectomy with ileal J pouch-anal anastomosis. RESULTS: There were no perioperative deaths. The overall morbidity rate was 31%. Six patients (21%) presented pelvic abscess; 2 (7%) pelvic hematoma, 4 patients (14%) ileo-anal anastomotic stricture, 1 patient (3.6%) pouch-vagina fistula, three patients (11%) intestinal obstruction and 7 (25%) pouchitis. All patients were able to evacuate their pouches spontaneously. The mean bowel movements were 6-9/24 hours at the first postoperative month and 3-5/24 hours at the sixth month. Infrequent nocturnal seepage occurred in 6 patients (21%). Stool consistency returned to normal within 3-6 months. The mean pouch capacity was 210 cc. The mean resting pressure was diminished in 11 patients (39%), the men and maximal squeeze pressures were improved in 9 (32%); the ileo-rectal-anal inhibitory reflex was normal in 5 patients (18%), not defined in 12 (43%). Impotence or impaired bladder function was not present. CONCLUSION: The use of staplers in the surgical technique of restorative proctocolectomy with J shaped ileo-anal pouch is associated with low morbidity and better long-term results. The procedure requires a good selection of patients, a correct surgical timing, a very carefully technique and a low pre and postoperative treatment with steroids.

Adult↗

PubMedDate not supplied

Restorative proctocolectomy: morphological and functional study with coronal CT.

BACKGROUND: Restorative proctocolectomy with ileal pouch has become the surgical treatment of choice for patients with ulcerative colitis (UC) and familial polyposis of the colon. Defecography is the radiological technique commonly employed to obtain detailed information on function and morphology of the ileal pouch; it allows the direct visualization of the ileal pouch and the anal canal, but it does not provide the visualization of the pelvis. METHODS: In all patients, computed tomography (CT) on coronal planes was performed to determine its possibilities as an alternative to defecography; 10 patients with UC submitted to restorative proctocolectomy and were examined. RESULTS: Coronal CT images provided a panoramic vision of the pelvis and demonstrated the morphology of the ileal pouch, the thickness of its walls, and its correlation with the surrounding tissues. Coronal CT also allowed the evaluation of the continence of ileo-anal and ileo-ileal anastomosis and the functional changes of the perineal muscles at rest and during squeezing. CONCLUSION: CT images acquired on coronal planes allows an easy and clear detection of the major postoperative complications, such as stenosis or dehiscences of the anastomosis, pelvic phlogosis, and fistulae.

Adenomatous Polyposis Coli↗

PubMed2005

Incidence and outcome of complications following restorative proctocolectomy.

BACKGROUND: Complications were analyzed in 296 patients with ulcerative colitis who underwent restorative proctocolectomy. METHODS: In 96.3% of patients, the pouch was anastomosed using the double stapling method. A total of 44.6% of patients underwent restorative proctocolectomy in 1 stage without ileostomy and 53% in 2 stages. Complications were divided into 2 stages: early (within 1 month) and late (after 1 month); moreover, the annual incidences were calculated, mean onset time, and pouch survival rate. RESULTS: The overall incidence of complications was 52.7%. Early complications (13.2%) occurred significantly less often than late complications (46.3%) (P < .05). Thirty-five (17.7%) of 198 complications required surgery. The cumulative 5- and 10-year pouch survival rate was 99%, respectively. CONCLUSIONS: The rate of complications after restorative proctocolectomy was almost equivalent to that in other reports, but the pouch survival rate was very high.

Adult↗

PubMed2006

A comparison of adverse events and functional outcomes after restorative proctocolectomy for familial adenomatous polyposis and ulcerative colitis.

PURPOSE: Restorative proctocolectomy is the procedure of choice for patients undergoing proctocolectomy for familial adenomatous polyposis or ulcerative colitis. This meta-analysis was designed to identify differences in adverse events and functional outcomes between these two groups. METHODS: Studies published between 1986 and 2003 that compared outcomes between patients with familial adenomatous polyposis and ulcerative colitis were included. Meta-analytical techniques using random effect models were used to compare short-term and long-term adverse events as well as functional outcomes between the groups. RESULTS: Nineteen studies comprising 5,199 patients (familial adenomatous polyposis, 782; ulcerative colitis, 4,417) were analyzed. There were no significant differences in immediate postoperative adverse events between the two groups. Pouch-related fistulation was significantly increased in the ulcerative colitis group (10.5 percent vs. familial adenomatous polyposis 4.8 percent; odds ratio 2.31; P < 0.001). There was no significant difference in pouch failure between the two groups (ulcerative colitis 5.8 percent vs. familial adenomatous polyposis 4.5 percent; odds ratio 1.22; P = 0.43). The incidence of pouchitis was significantly greater in the ulcerative colitis group (30.1 vs. 5.5 percent; odds ratio 6.44; P < 0.001). Patients with familial adenomatous polyposis had a significant advantage in stool frequency with one less motion per 24 hours (95 percent confidence interval, 0.21-1.76; P = 0.01). CONCLUSIONS: In contrast to studies reporting similar outcomes for patients undergoing restorative proctocolectomy for familial adenomatous polyposis or ulcerative colitis, the present meta-analysis suggested that patients with ulcerative colitis are at greater risk of pouch-related fistulation and pouchitis. Although there was an increase in the 24-hour stool frequency in the ulcerative colitis group, this may be accounted for by the younger age at surgery in the familial adenomatous polyposis group.

Adenomatous Polyposis Coli↗

PubMed1998

Incidence of neoplastic polyps in the ileal pouch of patients with familial adenomatous polyposis after restorative proctocolectomy.

PURPOSE: Although adenomatous polyps and even adenocarcinomas have been found in the terminal ileum of patients with familial adenomatous polyposis, the prevalence of neoplastic changes in the pouches of patients who have undergone restorative proctocolectomy is unknown. The objective of this study was to determine the frequency of pelvic pouch neoplasia in familial adenomatous polyposis patients after restorative proctocolectomy. METHODS: Patients in a polyposis registry who had undergone restorative proctocolectomy were recruited. Demographic, surgical, pathologic, and endoscopic data were obtained from patient records. Video pouchoscopy was done after two enemas and representative biopsies were taken. RESULTS: Of 102 eligible patients, 26 (17 males and 9 females) participated. Median age at ileal pouch-anal anastomosis was 31 (range, 12-58) years. Median follow-up period was 66 (11-156) months. Adenomas were found in the pouch of 11 (42 percent) patients, in the terminal ileum above the pouch in 1 patient, and in the anal canal of 4 patients. Among patients with pouch polyps, three patients had one lesion, three patients had two lesions, and five patients had more than ten lesions. The incidence of polyps increased steadily with time from restorative proctocolectomy. There was no relation between the incidence of pouch polyposis and the severity of colonic or duodenal disease. CONCLUSIONS: Proctocolectomy and ileal pouch-anal anastomosis is associated with a significant risk of pouch neoplasia in familial adenomatous polyposis patients. The severity of pouch adenomas was not related either to the severity of colonic or duodenal disease. The pelvic pouches of all patients with familial adenomatous polyposis who have undergone restorative proctocolectomy should be examined periodically.

Adenomatous Polyposis Coli↗

PubMed1992

One-stage restorative proctocolectomy without temporary defunctioning ileostomy.

A temporary ileostomy has been employed routinely by most medical centers to defunction the ileal reservoir after restorative proctocolectomy. The aim of this study was to compare the clinical outcome in patients who underwent restorative proctocolectomy with and without the use of a temporary, defunctioning ileostomy. A consecutive series of 58 patients was studied. Each patient underwent restorative proctocolectomy with quadruplicated ileal reservoir and stapled pouch-anal anastomosis, without mucosectomy; 28 had a temporary, defunctioning ileostomy and 30 did not. The decision for or against an ileostomy was taken at the end of the operation. The two groups of patients were similar in age and sex distribution. There was no postoperative mortality. There were no significant differences in the incidence of pelvic sepsis, anastomotic stricture, and intestinal obstruction in patients without an ileostomy compared with patients with an ileostomy. The total length of stay in hospital after the operation was significantly reduced in the group of patients without an ileostomy (P less than 0.01). The avoidance of a temporary ileostomy did not lead to an increase in postoperative complications and was associated with a shorter length of stay in hospital after restorative proctocolectomy.

Adult↗

PubMed1989

Anal canal mucosa in restorative proctocolectomy for ulcerative colitis.

In an attempt to improve continence after restorative proctocolectomy, ileal reservoir-anal anastomosis at the level of the anorectal junction has been advocated. This procedure preserves the entire mucosa of the anal canal. The histological appearances of the anal mucosa have been examined in 16 consecutive patients undergoing restorative proctocolectomy for ulcerative colitis. In 14 patients there was chronic inflammation characteristic of ulcerative colitis. Four patients had moderate dysplasia and in one of these patients an unsuspected adenocarcinoma of the anal canal extending down to the level of the dentate line was present. We believe that the anal mucosa should always be removed down to the level of the dentate line in restorative proctocolectomy for ulcerative colitis.

Anal Canal↗

PubMed1997

Results of restorative proctocolectomy in the elderly.

Twenty eight of 227 patients undergoing restorative proctocolectomy for inflammatory bowel disease, familial adenomatous polyposis or functional disease were over the age of 50 years: ages 50 to 60 (n = 13), 60 to 70 (n = 10), and over 70 (n = 5). Major complications occurred in 5 patients over the age of 50 (18%) compared with 43 patients under the age of 50 (23%). Three patients above the age of 50 had their pouch excised (11%) compared with 23 under the age of 50 (12%). Functional outcome was assessed with a 12 point symptom score. This was similar in all age bands: under 50 years (mean = 2.2; sd +/- 2.2; n = 109), 50 to 60 years (mean = 2.5; sd +/- 2.5; n = 12), 60 to 70 years (mean = 2.8; sd +/- 2.3; n = 7) and over 70 years (mean = 4.0; sd +/- 3.7; n = 5): P > 0.05). When analysed for ulcerative colitis alone, no significant differences were seen between the two age groups. Restorative proctocolectomy in the elderly gives results which are comparable to the younger population.

Adenomatous Polyposis Coli↗

PubMed1993

Experience with restorative proctocolectomy in 201 patients.

Two hundred and one patients underwent restorative proctocolectomy between January 1985 and January 1993. The underlying disease was ulcerative colitis in 191 and familial adenomatous polyposis in ten patients. All patients had a J pouch and, except for 22 patients, total mucosectomy was performed. The procedure was technically successful in 200 cases (99.5%). There was no postoperative mortality, but two patients died soon afterwards due to unrelated causes (suicide, upper gastrointestinal bleeding). Early postoperative complications were observed in 33% of patients and 21% required reoperations, most often because of haemorrhage or pelvic sepsis. Late morbidity rate was 29% including reoperations in 31 patients (17%) and conversion to permanent ileostomy in five cases (2.5%). The most common late problems were anal sinus, stricture or fistula (11%) and episodic or chronic pouchitis (20%). The functional result was evaluated in 150 patients followed up for one year. the mean bowel frequency was 5.6 times in 24 hours, 19% of patients had minor anal soiling and 11% required a protective pad. It is concluded that restorative proctocolectomy has become the first choice for most patients with ulcerative colitis and familial adenomatous polyposis.

Adenomatous Polyposis Coli↗

PubMed1993

Effect of anorectal eversion during restorative proctocolectomy on anal sphincter function.

Twenty-six patients underwent restorative proctocolectomy with end-to-end ileal pouch-anal anastomosis, without resection of the anal mucosa, by the eversion technique. Before surgery patients underwent tests of anorectal function. These were repeated a median of 8 (range 3-21) months after operation. The median (range) maximum resting anal pressure was 93 (36-149) cmH2O before and 71 (40-131) cmH2O after operation (P = 0.002). The median (range) maximum squeeze pressure before operation was 136 (73-280) cmH2O; it was 149 (69-290) cmH2O afterwards (P not significant). The median (range) length of the anal sphincter was 3.5 (2.5-4.5) cm before and 3.5 (2.0-4.5) cm after operation (P not significant). Thresholds for sensation in the upper, middle and lower thirds of the anal canal before and after operation were, respectively, 8.7 versus 8.7, 6.8 versus 7.4 and 4.2 versus 6.2 mA (P not significant). All 26 patients were continent, although one experienced minor leakage. Function of the anal sphincter is not significantly impaired by eversion of the rectum and anus during restorative proctocolectomy.

Adolescent↗