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PubMed2001

Familial adenomatous polyposis: prevalence of adenomas in the ileal pouch after restorative proctocolectomy.

OBJECTIVES: To determine the prevalence of adenomas in ileal pouches from patients with familial adenomatous polyposis (FAP) and to determine whether a correlation exists between the presence of pouch adenomas and duodenal adenomas and the site of the adenomatous polyposis coli gene mutation. SUMMARY BACKGROUND DATA: Restorative proctocolectomy can markedly reduce the risk of colorectal adenocarcinoma in FAP patients. However, adenomas with the potential to progress to adenocarcinoma can develop in the duodenum, ileum, and continent ileostomy after restorative proctocolectomy. More recently, adenomas have been described in the ileal pouch after ileoanal anastomosis. METHODS: Pouch endoscopy was offered to 167 patients with FAP who had undergone restorative proctocolectomy between January 1984 and December 1996. RESULTS: Adenomas were found in 35% of the 85 ileal pouches examined. No invasive carcinomas were noted. The risk of developing one or more adenomas at 5, 10, and 15 years was 7%, 35%, and 75%, respectively. Patients with adenomas were more likely to have duodenal and ampullary adenomas. No correlation was detected between adenoma development and the site of the adenomatous polyposis coli mutation. CONCLUSIONS: Adenomas are frequently found in the ileal pouch of patients after restorative proctocolectomy for FAP. Regular endoscopic surveillance of the pouch is recommended at a frequency similar to that of upper gastrointestinal endoscopy.

Adenomatous Polyposis Coli↗

PubMed2003

Elimination of mucosectomy during restorative proctocolectomy in patients with ulcerative colitis may provide better results in low-volume centers.

BACKGROUND: To compare the outcomes of hand-sewn and double-stapling techniques among ulcerative colitis patients undergoing restorative proctocolectomy at a center that has limited experience with restorative proctocolectomy. METHODS: Forty-four patients with ulcerative colitis were divided into two groups according to the anastomosis techniques: hand sewing and double stapling. Postoperative early and late complications, postoperative hospital stay, and long-term functional results were compared. RESULTS: Pelvic sepsis (9% versus 36%, P = 0.03), operation time (median 240 minutes versus 270 minutes, P = 0.01), postoperative hospital stay (median 9 days versus 12 days, P = 0.04), and night incontinence (42% versus 80%, P = 0.07) were less common in the double-stapling group. CONCLUSIONS: We recommend the double-stapling technique to centers that do not have extensive experience with restorative proctocolectomy for ulcerative colitis. This technique provides a good postoperative course in most patients and provides satisfactory long-term results. The results of the double-stapling group were similar to the results of the high-volume centers.

Adolescent↗

PubMed1997

One-stage restorative proctocolectomy without temporary ileostomy for ulcerative colitis: a note of caution.

PURPOSE: This study was designed to determine the safety of omitting a temporary defunctioning ileostomy in restorative proctocolectomy for ulcerative colitis. METHOD: One hundred consecutive patients with ulcerative colitis were treated electively by restorative proctocolectomy and pouch-anal anastomosis, without mucosal stripping; 50 had a defunctioning ileostomy added, and 50 underwent a one-stage procedure without ileostomy. RESULTS: There was no operative mortality. The incidence of postoperative complications was similar in the two groups of patients. Life-threatening complications, however, were more common among patients who did not have a defunctioning ileostomy, of whom 11 developed pelvic sepsis and 7 required reoperation. Among patients with an ileostomy, seven developed pelvic sepsis but none required reoperation (P < 0.02). Emergency reoperations were required in 11 patients without an ileostomy but in only 1 patient with an ileostomy (P < 0.01). CONCLUSION: One-stage restorative proctocolectomy without a defunctioning ileostomy is associated with increased risk to life. Its routine use cannot be recommended.

Adolescent↗

PubMed1999

Long-term functional outcome and quality of life after stapled restorative proctocolectomy.

OBJECTIVE: To evaluate prospectively long-term quality of life and functional outcome after restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis, and to evaluate and validate a novel quality-of-life indicator in this group of patients. SUMMARY BACKGROUND DATA: Restorative proctocolectomy with ileal pouch-anal anastomosis is now the preferred option when total proctocolectomy is required for ulcerative colitis or familial adenomatous polyposis, but long-term data on functional outcome and quality of life after the procedure are lacking. METHODS: Patients (n = 977) who underwent RPC with stapled anastomosis for colitis or polyposis coli and who were followed for > or =12 months were included. Quality of life, fecal incontinence, and satisfaction with surgery were prospectively evaluated by structured interview or questionnaire for 1 to 12 years after surgery (median 5.0). Quality of life was scored using the Cleveland Global Quality of Life (CGQL) instrument (Fazio Score). This is a novel score developed over the past 15 years by the senior author. Quality of life was also evaluated in a subgroup of patients with the Short Form 36 (SF-36). The CGQL was validated by determining its reliability, responsiveness, and validity as well as its correlation with the SF-36 score. RESULTS: Postoperative quality of life as measured by SF-36 was excellent and compared well with published norms for the general U.S. population. The CGQL was found to be reliable, responsive, and valid, and there was a high correlation with the SF-36 scores. Using the CGQL, quality of life was shown to increase after the first 2 years after surgery, and there was no deterioration thereafter. The prevalence of perfect continence increased from 75.5% before surgery to 82.4% after surgery, and although this deteriorated somewhat >2 years after surgery, it was no worse than preoperative values. Ninety-eight percent of patients would recommend the surgery to others. CONCLUSIONS: Long-term quality of life after ileal pouch surgery is excellent and the level of continence is satisfactory. This surgery is an excellent long-term option in patients requiring total proctocolectomy. The CGQL is a simple, valid, and reliable measure of quality of life after pelvic pouch surgery and may well be applicable in many other clinical conditions.

Aged↗

PubMed2006

Restorative proctocolectomy with an ileoanal pouch: the role of laparoscopy.

OBJECTIVES: The Aim of this retrospective study was to evaluate early experience with laparoscopic restorative proctocolectomy by analyzing the perioperative results of surgical treatment. PATIENTS AND METHODS: Seven major surgeries were performed in six patients with familial adenomatous polyposis and ulcerative colitis. All procedures were performed under laparoscopy at our third-level hospital from June 2003 to October 2004. RESULTS: Mean surgical time was 287.5 +/- 80.7 min, and median blood loss was 300 +/- 249.0 cc. There were no conversions; return of peristalsis began at 32 +/- 12.4 h; average time to first oral intake was 64.0 +/- 32.8 h, and mean duration of hospital stay was 9.3 +/- 1.2 days. There was one case of perineal sepsis due to ileal pouch-anal anastomotic leakage, which was successfully treated with oral intake restriction, parenteral nutrition, and intra-rectal drainage. The most common postoperative complication was postoperative ileus. CONCLUSIONS: We believe that the laparoscopic approach to restorative proctocolectomy may be considerably improved in our center. Particular aspects for improvement include efforts to achieve lower operating and hospitalization times to equate our results with those reported by multicenter studies for laparoscopic colon cancer surgery. In our opinion, learning and further training opportunities should be encouraged to improve surgeon experience in the field of laparoscopy, preferably at centers specializing in restorative proctocolectomy.

Adenomatous Polyposis Coli↗

PubMed2005

Risk factors associated with ileal pouch-related fistula following restorative proctocolectomy.

INTRODUCTION: Pouch-related fistula occurs in 5-10 per cent of patients after restorative proctocolectomy. The present study identified risk factors associated with the development of such fistulas. METHODS: Data on preoperative and postoperative risk factors were recorded from 1965 patients who underwent restorative proctocolectomy in a single tertiary centre between 1983 and 2001. Cox regression analysis was used to identify independent predictors of pouch-perineal, pouch-abdominal wall and pouch-vaginal fistula during follow-up. RESULTS: Median patient follow-up was 4.1 (range 0-19) years. By 15 years' follow-up, pouch-vaginal fistulas had occurred in 44 women (5.2 per cent). The prevalence of ileal pouch-perineal and pouch-abdominal wall fistula was 3.6 per cent (70 patients) and 1.5 per cent (30 patients) respectively. Independent predictors of pouch-related fistula identified by multivariate analysis were diagnosis of indeterminate colitis or Crohn's disease (hazard ratio (HR) 1.28 (95 per cent confidence interval (c.i.) 1.00 to 1.65) and 1.73 (95 per cent c.i. 1.07 to 3.48) respectively versus ulcerative colitis or familial adenomatous polyposis), previous anal pathology (HR 3.43 (95 per cent c.i. 2.43 to 4.84) and 4.02 (95 per cent c.i. 1.27 to 12.77) respectively for perineal abscess and fistula in ano versus no previous anal pathology), abnormal anal manometry (HR 4.29 (95 per cent c.i. 2.33 to 7.91)), patient sex (HR 0.74 (95 per cent c.i. 0.58 to 0.95) for men versus women) and pelvic sepsis (HR 3.79 (95 per cent c.i. 2.48 to 5.79)). CONCLUSION: This study suggests that Crohn's disease and the clinical signs that favour the diagnosis of Crohn's disease may contribute to the development of pouch-related fistula.

Abdominal Wall↗

PubMed1995

Surgery for the teenager with familial adenomatous polyposis: ileo-rectal anastomosis or restorative proctocolectomy?

Increasing numbers of polyposis registries have led to more young patients being diagnosed with familial adenomatous polyposis (FAP). To provide guidelines for selecting the appropriate surgical procedure in teenagers (10-19 years), we compared the results of colectomy and ileo-rectal anastomosis (IRA, n = 17 patients) to the results of restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA, n = 7 patients). Charts were reviewed to obtain data on the operative technique, blood loss and transfusions, hospital stay (including the time for ileostomy closure), and early (within 30 days of surgery) and late complications. Functional results (bowel movements per 24 h, use of antidiarrheal drugs, seepage, and fecal incontinence) and quality of life were evaluated prospectively with a questionnaire and physical examination. The median follow-up time was 49 months (range, 6 to 95 months) after IRA, and 36 months after IPAA (range, 4 to 87 months). Although restorative proctocolectomy and IPAA, is a longer (5.75 vs 3.1 hours), more bloody (500 vs 300 mL blood loss), and more complex operation with a longer hospital stay (12 vs 7 days) than IRA (P = 0.008, P = 0.006, P = 0.02, respectively), no significant difference (P > 0.05) was found between groups concerning the complication rate or quality of life. For teenagers with FAP and rectal carpeting, large rectal adenomas, curable cancer in the upper two-thirds of the rectum, or who are unavailable for follow-up, we recommend a restorative proctocolectomy and IPAA. For the other patients, the decision whether to perform IRA or restorative proctocolectomy with IPAA depends on the patient's desire and the surgeon's skill.

Adenomatous Polyposis Coli↗

PubMed2005

The impact of the fecal stream and stasis on immunologic reactions in ileal pouch after restorative proctocolectomy for ulcerative colitis: a prospective, pilot study.

OBJECTIVE: The etiology of pouch inflammation after restorative proctocolectomy is unknown. The fecal stream and immunological reactions are potential pathological factors. This study was performed to examine the impact of the fecal stream and stasis on immunological reactions in the pouch. METHODS: Patients who underwent a restorative proctocolectomy with a covering ileostomy for ulcerative colitis were studied. Mucosal biopsy specimens were obtained from both the pouch and the proximal ileum at the time of ileostomy closure, and 3, 6, and 12 months after ileostomy closure. As a control group, normal ileal biopsies were obtained from patients with colonic polyps. RESULTS: At the time of ileostomy closure, mucosal interleukin-1beta, interleukin-6, interleukin-8, and tumor necrosis factor-alpha levels in the pouch and the proximal ileum were not significantly different from those in the normal control group. At 3 months after ileostomy closure, the mucosal cytokine levels in the pouch increased significantly compared with those at ileostomy closure, and their levels were significantly higher than those in the proximal ileum. At 6 and 12 months after ileostomy closure, the mucosal cytokine levels in the pouch did not change significantly compared with those at 3 months after ileostomy closure. The mucosal cytokine levels in the proximal ileum did not change significantly during the entire study. CONCLUSIONS: The immunological reactions in the pouch occurred soon after ileostomy closure, and continued for at least 1 yr. The fecal stream and stasis play an important part in the pathogenesis of immunological reactions in the ileal pouch.

Adult↗

PubMed1992

Restorative proctocolectomy--the pouch operation: good or bad?

Restorative proctocolectomy is now the procedure of choice for patients requiring surgery for ulcerative colitis and some for familial adenomatosis. The indications for operation are being refined, and technically the procedure has been simplified. Although it avoids ileostomy, it does not restore normality. Stool frequency, continence problems, and pouchitis can all spoil a good result. In spite of these shortcomings, it represents a major advance.

Adenomatous Polyposis Coli↗

PubMed1993

Fistula complicating restorative proctocolectomy.

Twenty-seven patients developed a fistula after 168 restorative proctocolectomies. Thirteen fistulas were enterocutaneous (two with communication to the bladder); their origins were from the pouch (three patients), the ileoanal anastomosis (three), the pouch appendage (three), a previous loop ileostomy (two) and iatrogenic small bowel injury (two). Two patients had Crohn's disease. The pouch was removed in four patients, one of whom died from chronic small bowel obstruction; the remaining nine have satisfactory pouch function after fistula excision. Ten pouch-vaginal fistulas occurred, all from the ileoanal anastomosis; four were extrasphincteric. Four of these patients had underlying Crohn's disease. Only two patients, with Crohn's disease and indeterminate colitis, required pouch excision; the remainder have good pouch function after treatment of the fistula. There were three pouch-perineal fistulas, all from the ileoanal anastomosis; these were successfully managed by seton fistulotomy. There was one pouch-vesical fistula, successfully treated by excision of the fistula and pouch appendage.

Colonic Diseases↗

PubMed1998

[Long-term results after restorative proctocolectomy and ileoanal pouch in children with familial adenomatous polyps].

Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) is considered the therapy of choice for the prophylactic treatment of FAP in adults, while straight ileoanal endorectal pull-throughs were often favored in children. However, our experience with five children undergoing an ileoanal J-pouch procedure under the age of 15 years (7-15) due to early onset of a severe symptomatic FAP phenotype suggests results which are superior to those after direct ileoanal anastomosis. Even after a primary straight ileoanal pull-through with local complications and a high defecation rate, secondary IPAA should be considered.

Adenomatous Polyposis Coli↗

PubMed1995

Preservation of complete anal sphincteric proprioception in restorative proctocolectomy: the inhibitory reflex and fine control of continence need not be impaired.

This study evaluates whether reflux function of the anal sphincter remains unchanged after restorative proctocolectomy, provided that the sphincter remaining is kept intact, without mucosal stripping or endo-anal anastomosis. Paired tests of anorectal function were performed before, and a median of 6 (range 2-12) months after restorative proctocolectomy with stapled, end to end pouch-anal anastomosis. Beforehand, distension of the rectum with 50 ml of air produced a median (interquartile range) increase in pressure within the rectum of 22 (15-29) cm H2O and reflex inhibition of the anal sphincter from a pressure of 76 (62-106) cm H2O to a pressure of 34 (15-52) cm H2O. After the procedure, distension of the ileal pouch with 50 ml of air produced an increase in pressure within the pouch of only 5 (4-8) cm H2O (p < 0.001 compared with beforehand) and reflex inhibition of the anal sphincter from a pressure of 62 (25-79) cm H2O to 37 (17-68) cm H2O. Maximal reflex inhibition of the upper third if the anal sphincter to a pressure of 26 (15-48) cm H2O was observed when pressure within the pouch increased by 16 (11-22) cm H2O. After restorative proctocolectomy, all patients were continent (two experienced minor nocturnal leakage of mucus) and 25 could discriminate between flatus and faeces. Thus, reflux function was preserved in response to changes in pressure, ensuring that the subtler aspects of anal continence were preserved.

Adolescent↗

PubMed1994

Internal anal sphincter activity after restorative proctocolectomy for ulcerative colitis: a study using continuous ambulatory manometry.

PURPOSE: The aim of this study was to further investigate continuous ambulatory anal manometry which has recently been introduced as a method for studying anorectal activity in ambulant patients, thereby avoiding many of the potential drawbacks of static techniques. METHOD: In this study continuous ambulatory manometry was used to assess the activity of the internal anal sphincter in patients who had undergone restorative proctocolectomy, and, in particular, to compare patients who had undergone conventional mucosal proctectomy with sutured endoanal, ileoanal anastomosis with patients who had undergone restorative proctocolectomy with preservation of the entire anal canal by means of stapled, end-to-end, ileoanal anastomosis without mucosectomy. RESULTS: Evidence of basal internal sphincter activity was found in only 38 percent of patients after mucosal proctectomy with sutured endoanal anastomosis, whereas all patients after restorative proctocolectomy with stapled end-to-end anastomosis and all control individuals showed such activity of the internal sphincter. Similarly, the number of sampling episodes seen in patients after mucosal proctectomy with endoanal anastomosis was significantly less (median, 0.0/hours (0-30/hours)) than the number of sampling episodes observed in patients after end-to-end anastomosis (median, 4.5/hours (1-48/hours)) or in control individuals (median, 5.6/hours (0-31/hours)) (P < 0.001). CONCLUSIONS: These results suggest that the internal anal sphincter is damaged in the course of mucosal proctectomy and endoanal anastomosis. In contrast, after restorative proctocolectomy with stapled, end-to-end anastomosis normal function of the internal sphincter is preserved.

Adult↗

PubMed1997

Restorative proctocolectomy for idiopathic megarectum: postoperative recovery of hypotonic anal sphincters. Report of two cases.

PURPOSE: Restorative proctocolectomy has been advocated in the treatment of idiopathic megacolon, provided there is normal sphincter function. We report two patients undergoing this procedure, despite abnormal sphincter function. METHODS: Anorectal manometry and detailed symptom review were performed both preoperatively and at various stages postoperatively in two young patients with idiopathic megarectum. RESULTS: Both patients had progressive sphincter recovery postoperatively, shown both manometrically and with symptomatic review. CONCLUSION: Low preoperative sphincter pressures in young patients with idiopathic megarectum may not preclude successful outcome after restorative proctocolectomy.

Adult↗

PubMed1995

Effect of rectosigmoid stump length on restorative proctocolectomy after subtotal colectomy.

BACKGROUND: The length of the rectosigmoid stump left after subtotal colectomy and ileostomy is believed to affect postoperative complications, including sepsis, success of future restorative proctocolectomy, and long-term functional outcome. METHODS: We reviewed the charts of 60 patients with toxic ulcerative colitis who were treated with subtotal colectomy leaving either a short (25) or long (35) rectosigmoid stump and who eventually underwent restorative proctocolectomy between 1983 and 1992 at a large tertiary care center. Data were collected on preoperative disease duration and steroid use, operative time, blood loss, transfusion requirements, length of stay, stool frequency, fecal incontinence, and sexual dysfunction. RESULTS: There were no statistically or clinically significant differences between groups. CONCLUSIONS: Rectosigmoid stump length does not appear to affect complications or long-term outcome in patients with toxic ulcerative colitis treated with subtotal colectomy and restorative proctocolectomy.

Adult↗

PubMed2004

Restorative proctocolectomy in patients with ulcerative colitis having a recto-vaginal fistula.

OBJECTIVE: Recto-vaginal fistula is a rare complication of ulcerative colitis. There are few reports of restorative proctocolectomy carried out in patients with ulcerative colitis having a rectovaginal fistula. We report our experience with this condition. PATIENTS AND METHODS: Between 1 January 1976 and 31 December 2001, 838 patients underwent restorative proctocolectomy for ulcerative colitis at one hospital. These included 400 women of whom 4 (1%) had an already present rectovaginal fistula. We reviewed all patients who presented with a rectovaginal fistula. These patients were contacted by telephone to establish function and satisfaction. RESULTS: The mean age was 30.0 years (range 19-39 years). The mean age at onset of ulcerative colitis was 21.5 years (range 13-34 years). One patient was asymptomatic, the fistula being discovered at operation. In the other three patients the recto-vaginal fistula had occurred at a mean of 108 months (range 72-192 months) after the onset of ulcerative colitis. Three of four patients had had previous episodes of acute severe disease. Three patients had a narrow rectum with deep ulceration. The mean distance between the anorectal junction and the site of fistulation was 2.7 cm (range 0-7 cm). Three patients had a three-stage and one patient a two-stage procedure. Mean follow-up after closure of the loop ileostomy was 107 months (range 17-276 months). All patients were treated successfully but 2 (50%) had a recurrence at 156 and 40 months after the closure of the loop ileostomy. One patient was diverted and the fistula was closed by a subsequent transanal repair and the other patient was treated with success by temporary loose seton technique. Two patients had excellent functional results whereas two other had some difficulties in continence. Nevertheless all patients were satisfied with the outcome. CONCLUSIONS: Patients with ulcerative colitis and a recto-vaginal fistula can be successfully treated by restorative proctocolectomy, nevertheless they are at risk of late recurrence of the fistula.

Adult↗

PubMedDate not supplied

[Restorative proctocolectomy with J-pouch reservoir. Experience in a national medical center].

OBJECTIVE: To present the experience for morbidity and mortality of surgical treatment of chronic ulcerative colitis (CUC) and familiar adenomatous polyposis (FAP) with restorative proctocolectomy with J-pouch. MATERIAL AND METHODS: We used a cases series of patients treated consecutively from January 1993 to December 2003. Selection criteria were patients with J-pouch restorative proctocolectomy with CUC and FAP who were treated and assessed prospectively. RESULTS: There were 16 cases treated with restorative proctocolectomy (nine males and seven females). Diagnosis of inflammatory bowel disease was established in 12 patients, and 4 with familiar adenomatous polyposis. Age average was 33 years. All cases had protective ileostomy. Seven patients developed at least one complication such as pelvic abscess, uretheral transection, pulmonary thromboembolism, hemoperitoneum, persistent transrectal bleeding, wound infection and sexual impotence. Only four patients required surgical reintervention. The median hospital stay was 11.9 days. Average bowel movements at 3 month-follow-up was 10.1, at 6 months 6.6. Medium average follow-up was 44.25 months. There was no mortality. CONCLUSIONS: Results of this study demonstrated adequate quality of life and appropriate functional results; rate of morbidity was acceptable with no mortality.independent of morbidity there was no mortality. Long-term follow up is necessary to identify long-term-late complications.

Adenomatous Polyposis Coli↗

PubMed1992

Randomized trial of loop ileostomy in restorative proctocolectomy.

A randomized controlled trial was performed to assess the role of loop ileostomy in totally stapled restorative proctocolectomy. Entry criteria included all patients who were not on corticosteroids in whom on-table testing revealed a watertight pouch with intact ileoanal anastomosis. Of 59 patients undergoing restorative proctocolectomy over 36 months, 45 were eligible and were randomized to loop ileostomy (n = 23) or no ileostomy (n = 22). The age and diagnosis of the groups were similar. There were no deaths; two ileoanal anastomotic leaks occurred, one in each group. Ileoanal stenosis occurred in five patients with and one without an ileostomy. The incidences of wound and pelvic sepsis, bowel obstruction and pouchitis were similar. Twelve patients (52 per cent) developed ileostomy-related complications. The median total hospital stay was 23 (range 13-75) days with ileostomy and 13 (range 7-119) days without (P < 0.001). This study indicates that there is a low risk of pelvic sepsis which is not increased by avoiding a protective ileostomy. Loop ileostomy was associated with a high incidence of complications.

Adolescent↗