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PubMedDate not supplied

Restorative proctocolectomy: histological assessment and cytometric DNA analysis of ileal pouch biopsies.

BACKGROUND/AIMS: The pathological changes and the risk of developing cancer in the ileal pouch mucosa of patients who received restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) were studied. The presence or absence of remaining rectal mucosa below the IPAA in both patients with stapled and handsewn IPAA was also examined. MATERIALS AND METHODS: Endoscopy of the ileal pouch was performed on 38 patients at 4, 12, 18 and 36 months after restorative proctocolectomy with ileal pouch. Mucosal biopsy specimens were taken from the ileal reservoir in order to assess the histological incidence of inflammation. In 23 patients, biopsies were taken to perform cytometric DNA analysis. Clinical symptoms of pouchitis (over six evacuations in 24 hours, night-time evacuations, leakage of feces, bloody diarrhea, abdominal pain and fever) were recorded and correlated with the histological findings. Biopsies were also sampled below the ileo-anal anastomosis (IPAA) in order to identify residual rectal mucosa. RESULTS: Results of histological assessment showed various degrees of chronic inflammation increasing over time (from 42 to 60%) while the presence of both acute and chronic inflammation of the reservoir was less frequent (from 18 to 30%). Villous atrophy was present in 39-68% of patients and the grade of villous atrophy was correlated to the grade of inflammation. Clinical pouchitis was present in 3 to 8% of cases at the different controls and it was always associated with the highest grade of histological inflammation and severe villous atrophy. No significant alteration of the DNA cellular content was observed. Very low incidence of aneuploidy (0.7-1% Ex.R.) has been reported in three cases. However, we found dysplasia in only one patient who underwent surgical treatment for familial polyposis coli. IPAA evaluation showed no residual rectal mucosa in 40% of cases with stapled IPAA; in the remaining 60%, we found a small amount of rectal mucosa (maximum 1 cm). We did not find rectal mucosa after handsewn IPAA with mucosectomy. CONCLUSIONS: Patients treated with restorative proctocolectomy with IPAA showed a higher and increased incidence of inflammation during follow-up. No significant alteration of DNA cellular content nor dysplasia of the pouch mucosa were observed. In this study the chance of leaving rectal mucosa after stapled IPAA was about 60%.

Adolescent↗
PubMed1993

Similar functional results after restorative proctocolectomy in patients with familial adenomatous polyposis and mucosal ulcerative colitis.

Restorative proctocolectomy (RP) is generally considered to achieve better results in patients with familial adenomatous polyposis (FAP) than in those with mucosal ulcerative colitis (MUC). We studied 39 pairs of patients (FAP versus MUC), individually matched for surgeon (n = 4), types of ileal pouch (19 S-pouches and 20 J-pouches), technique of ileal pouch-anal anastomosis (21 stapled, 18 handsewn with mucosectomy), duration of follow-up after pouch function (median: 32 months; range: 6 months to 8.5 years), age (median: 30 years; range: 12 to 60 years), and gender (male-to-female ratio: 1.4:1.0). The median duration of operation (3.2 hours), hospital stay (9 days), and the amount of blood loss (about 650 mL) were similar between the two groups. The patients in the MUC group tended to have a higher overall complication rate (28% versus 21%) and more pouch-related septic complications (13% versus 8%, p = 0.6 by chi 2 analysis). Functional results were similar for daytime (median: 5 per day) and nighttime (median: 1 per night) stool frequency and the median duration that defecation could be deferred (median: about 1.5 hours). Perfect continence was present in 34 (87%) patients during the day and in 19 (49%) patients during the night in each group. The use of antidiarrheal medications did not differ between the two groups. According to an analogue scale (from 1 to 10, with 10 being best), the quality of life and health and satisfaction with outcome (median score: 9) were identical between the groups. Thus, in closely matched groups of patients with FAP and MUC, the functional outcome after RP was similar. However, pouchitis was more common in the MUC group (33% versus 10%, p < 0.05 by chi 2 analysis).

Adenomatous Polyposis Coli↗
PubMed1994

The first 10 years' experience of restorative proctocolectomy for ulcerative colitis.

Between 1976 and 1985, 110 patients had restorative proctocolectomy or proctectomy for ulcerative colitis and 103 were followed up until death or February 1992. There was one postoperative and one late death related to surgery. The cumulative probability of pouch failure was 12% at five years: half of the failures occurred within one year. The commonest reasons were perianal/pelvic sepsis and probable Crohn's disease. The cumulative probability of readmission, excluding that for ileostomy closure, was 68% at five years. There were 152 operations carried out during readmissions. These included 44 laparotomies. Function was assessed in 80 patients at a mean of 99.3 months after ileostomy closure. For 66 patients with spontaneous evacuation, average minimum diurnal frequency was 3.8, maximum 4.9, with 35 evacuating at night. One patient experienced major continence problems, 30 had minor leaks, and 49 were completely continent. Postoperatively, five patients gave birth to nine babies, four had renal stones, two myasthenia gravis, and two severe anaemia: seven had pre or postoperative thyroid dysfunction.

Adolescent↗
PubMed2003

Management of ovarian cysts in women undergoing restorative proctocolectomy for ulcerative colitis.

More than half of all patients undergoing restorative proctocolectomy (RP) for ulcerative colitis (UC) are women, yet there is a paucity of information regarding the frequency, management, and outcome of ovarian cysts. A single surgeon's (E.W.F.) experience with female patients (N = 165) who underwent RP for UC at an academic medical center was retrospectively evaluated for postoperative complications and overall outcome. Patients with large ovarian cysts (LOCs), defined as being greater than 5 cm in diameter, were further segregated for subanalysis. All results were analyzed using the Student's t test and Fisher's exact test. Patients were 29.3 +/- 13 years (mean) at the time of RP; 34 patients were less than 16 years old (21%), 113 patients (68%) were between the ages of 17 and 46 years, and 18 patients were over 46 years old (11%). All patients underwent total colectomy, mucosal proctectomy ileal pouch-anal anastomosis, and temporary end ileostomy. The ileostomy was closed 3 months later. Fifty-five of the 165 patients had ovarian cysts (33%) identified at operation, 46 had unilateral cysts, and nine had bilateral cysts. Mean ovarian cyst size was 4.6 +/- 2.7 cm (range <1-13 cm); 14 were LOCs. Patients with cysts <3 cm in diameter at operation were treated by observation with hormonal manipulation. Seventeen patients with cysts 3 to 5 cm in diameter required partial resection of one or both ovaries. Six of 14 patients with LOC underwent unilateral oophorectomy (cyst size range 10-13 cm). Twelve patients presented within 3 years after RP with malfunction of the pouch because of adhesions or minimal and uncontrolled passage of fecal material (soiling), partial obstruction due to LOC compression of the ileoanal pouch (n = 6), or adhesions. When evaluated on the basis of ovarian cyst size those without cysts and those with small cysts were significantly more likely to have children than those with LOC: 54 of 110 patients without cysts (49%), 18 of the 41 with cysts less than 5 cm in diameter (44%), and two of the 14 patients with LOC (14%) have had children (P = 0.047). Ovarian cysts are common in women undergoing RP for UC. Ovarian cysts often complicate postoperative intestinal function and are best treated by cyst resection or oophorectomy at the time of RP or ileostomy closure. Cysts under 3 cm in diameter may often be managed conservatively with few complications. Women with LOC after RP for UC have decreased fertility compared with those without cysts.

Colitis, Ulcerative↗
PubMed1996

Comparison of sutured and stapled closure of loop ileostomy after restorative proctocolectomy.

Twenty consecutive stapled loop ileostomy closures in patients treated by restorative proctocolectomy were compared with the previous 20 sutured loop ileostomy closures in a non-randomised audit. Complications occurred in six of 20 stapled closures compared with seven of 20 sutured closures. Operating time and hospital stay were similar. The additional expense of stapling does not seem justified as complication rates, operating time and hospital stay are similar to sutured closures.

Adolescent↗
PubMed1997

The impact of the development of restorative proctocolectomy on the management of inflammatory bowel disease in the north of Scotland.

In the North of Scotland, 40 out of 196 patients who had surgery for colitis between 1986 and 1992 underwent restorative proctocolectomy. The problems of the development of experience in a new technique were reduced by cooperation between two consultant surgeons from centres 100 miles apart who performed the first 30 operations together. Over 7 years, the standard operative technique evolved from perimuscular dissection of the rectum with formation of an S pouch and hand sutured endo-anal anastomosis to perimesenteric rectal dissection with a stapled J pouch and double stapled anastomosis. There was no mortality and no pelvic sepsis requiring urgent re-operation. One pouch has been removed subsequently because of Crohn's disease. One patient required revisional surgery for severe stricture of the ileo-anal anastomosis. At 1 year post-operatively, 35 out of 40 patients were highly satisfied with the result of surgery. The proportion of patients undergoing restorative proctocolectomy rather than panproctocolectomy for ulcerative colitis has risen from 15 to 52%. The number of total colectomies performed as initial procedures for colitis has increased. The age of patients who have restorative proctocolectomy has widened to include teenagers as well as a few patients over 50 years of age.

Adolescent↗
PubMed2000

Mucosal changes in ileal pouches after restorative proctocolectomy for ulcerative and Crohn's colitis.

PURPOSE: Inflammation and dysplasia may affect the ileal pouch after restorative proctocolectomy and ileal pouch-anal anastomosis. The aim of this prospective study was to evaluate the morphologic changes and the risk of dysplasia within the pouch after ileal pouch-anal anastomosis. METHODS: Thirty-seven patients with ileal pouch-anal anastomosis underwent endoscopies and biopsies of the pouch: 21 patients were affected by ulcerative colitis and 16 by Crohn's colitis. The mucosal biopsy specimens were studied to investigate the degree of acute and chronic inflammation and the occurrence of dysplasia. A score system was calculated for each patient and correlated with the histologic diagnosis of ulcerative colitis or Crohn's colitis. RESULTS: After a median follow-up of 85 (range, 7-198) months, the inflammation histologic score evaluated was 3.8 (95 percent confidence interval, 2.4-5.1) and 3.5 (95 percent confidence interval, 2.6-4.3), respectively, in patients with Crohn's colitis and ulcerative colitis (mean and 95 percent confidence interval; P = 0.74, not significant), and no patient developed mucosal dysplasia. Fifteen patients (40.5 percent) developed clinical pouchitis that occurred in Crohn's colitis (9/16 patients or 56 percent) and in ulcerative colitis (6/21 patients or 28 percent; P not significant). The score was 4.1 (95 percent confidence interval, 3.2-5) in patients with pouchitis and 3.2 (95 percent confidence interval, 2.1-4.3) in patients without clinical pouchitis (P = 0.012) and was 4.1 (95 percent confidence interval, 2.6-5.5) and 4 (95 percent confidence interval, 2.9-5.3), respectively, in pouchitis patients with Crohn's colitis and ulcerative colitis. CONCLUSION: No difference in the inflammation histologic score was observed in ileal pouches after restorative proctocolectomy for ulcerative and Crohn's colitis. In our series, which includes those patients with longer follow-up (>5 years) or with chronic unremitting pouchitis, no case of dysplasia was found. The occurrence of pouchitis was higher in the case of ileal pouch-anal anastomosis for Crohn's disease than for ulcerative colitis, but no difference in the severity of the histologic score was noted.

Adult↗
PubMed1993

Possible role of the autonomic nervous system in sphincter impairment after restorative proctocolectomy.

Peroperative manometry was performed in 12 patients operated on with endoanal proctectomy and a hand-sewn pouch-anal anastomosis and in 12 in whom proctectomy was performed entirely from above, with the ileal pouch stapled to the top of the anal canal. Results from both groups showed that division of the superior rectal artery reduced the median (95 per cent confidence interval (c.i.)) resting anal pressure from 77.5 (69.9-83.3) mmHg to 64.5 (55.2-70.0) mmHg (P < 0.01). Complete rectal mobilization to the pelvic floor decreased resting pressure by an additional 22 per cent, to a median of 50.0 (95 per cent c.i. 40.1-53.5) mmHg (P < 0.01). After completion of anastomosis, irrespective of the operative technique used, a further decline in median pressure to 35.0 (95 per cent c.i. 26.0-47.7) mmHg could be demonstrated (P < 0.05). This study indicates that anal sphincter pressure is reduced to a similar extent after hand-sewn and stapled anastomoses. Injury to the autonomic nervous supply to the anal sphincter mechanism might be the major cause for this reduction.

Adult↗
PubMed1996

Anal transitional zone and columnar cuff in restorative proctocolectomy.

The popularity of double stapling the ileal pouch-anal anastomosis probably owes more to the technical ease it brings than to histological considerations or functional results. It is preservation of a 'columnar cuff' of mucosa, rather than the restricted site of the anal transitional zone, that should be the focus of research with respect to long-term risk of malignancy and inflammatory complications. If cancer is present in colon that has been removed for ulcerative colitis, there is a 25 per cent incidence of dysplasia in the columnar cuff in the short term. In other circumstances, those who are spared from carcinoma by colectomy are likely to have a similar risk of developing dysplastic change in the columnar cuff with longer follow-up. Double stapling the pouch-anal anastomosis and preserving the anal canal mucosa improves function, but long-term surveillance of the columnar cuff is then required, including biopsies.

Anal Canal↗
PubMed1996

Pouch-related fistula following restorative proctocolectomy.

Prognostic factors and outcome of pouch-related fistula were analysed from a series of 21 patients, 20 of whom had an ileal J pouch manually anastomosed to the dentate line following mucosectomy. Fistula occurred more often after pouch formation for ulcerative colitis than for familial adenomatous polyposis. In 6 patients the fistula occurred more than 5 months after closure of the diverting loop ileostomy. The origin of the leak was the anastomosis in 14 patients, the vertical staple line in two and the end of the efferent limb in five. Nine forms of treatment were utilized and these were successful in 11 patients and unsuccessful in ten including three pouch excisions. Adverse prognostic factors were late fistula, the presence of an enterocutaneous or a pouch-vaginal fistula track, and diagnosed or suspected Crohn's disease. Resolution of the fistula followed none of six diverting loop ileostomies performed alone, three of 33 attempted drainage procedures, four of ten direct closures, and four of five repeat ileal pouch-anal anastomoses. It is concluded that an aggressive therapeutic approach using repeat ileal pouch-anal anastomosis increases the success rate.

Adenomatous Polyposis Coli↗