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PubMed1992

The role of the defunctioning ileostomy in restorative proctocolectomy.

Restorative proctocolectomy is now the treatment of choice for most patients with ulcerative colitis and familial polyposis coli. Temporary defunctioning ileostomy has been advocated during the period of anastomotic healing to prevent pelvic sepsis. However, the ileostomy itself may be a source of significant complications. To examine ileostomy function we reviewed thirty five patients (mean age 34.5 +/- 1.95 years) who underwent restorative proctocolectomy. Thirty four patients had a defunctioning ileostomy established at the time of pouch anal anastomosis. Closure of the ileostomy has been carried out in 33 patients (mean closure time 3.1 +/- 0.29 months). One patient underwent early pouch excision. Thirteen of the 35 patients developed post-operative complications (37%), two directly related to the defunctioning ileostomy. Both occurred following closure of the stoma and required laparotomy. Serious complications associated with defunctioning ileostomy as demonstrated in this study are uncommon (8.5%). Given the potentially disastrous consequences of a pouch-anal anastomotic leak we feel that the relatively low morbidity associated with a defunctioning ileostomy justifies its continued routine usage in the operation of restorative proctocolectomy.

Adenomatous Polyposis Coli↗

PubMed2001

Adenocarcinoma in the ileal pouch: late risk of cancer after restorative proctocolectomy.

Restorative proctocolectomy and ileal pouch-anal anastomosis is the surgical treatment of choice for patients with ulcerative colitis. As a long-term complication of this procedure, chronic pouchitis impairs the outcome in a number of patients. Aneuploidia and dysplasia have been observed after long-lasting inflammation of ileal mucosa. The question arises whether chronic inflammation of ileal mucosa predisposes to malignant transformation similar to the situation in the chronically inflamed colon. Cancer of the ileal mucosa has been reported in patients with Brooke's ileostomy and in patients with Kock pouch but not as yet in those with an ileoanal pouch. We report a patient with carcinoma in an ileoanal pouch originating from terminal ileal mucosa who had been suffering from pancolitis with long-term backwash ileitis before, and from chronic pouchitis after, restorative proctocolectomy. This case demonstrates the importance of regular follow-up with pouchoscopy and random biopsies in all patients with long-standing inflammation of the ileal mucosa.

Adenocarcinoma↗

PubMed1991

Clinical and functional outcome after restorative proctocolectomy.

Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) has been carried out on 88 patients since 1982. Three different pouch designs (J, S and W) were used. Ten pouches had to be removed. Detailed analysis was performed on 61 patients (J = 23, S = 15, W = 23) whose pouches had been functioning for at least 6 months. There was no significant difference in surgical complications before or after ileostomy closure between pouch designs but the hospital stay was greater after construction of an S pouch (P less than 0.05). There were no significant differences in stool frequency, degree of continence or urgency between the three types. Twelve patients with J pouches required antidiarrhoeal medication compared with only one with S and five with W pouches. Only seven patients with S pouches could defaecate spontaneously compared with 22 with W pouches and all patients with J pouches (P less than 0.001). Twenty-five of 29 patients who had preservation of the anal transition zone had perfect continence compared with 23 of 32 with a mucosal proctectomy (P = n.s.). Pouchitis occurred in 13 patients, all of whom had ulcerative colitis. In a subgroup of 23 patients, pouch evacuation was assessed scintigraphically. There was no difference in pouch capacity or total volume evacuated, but spontaneous evacuation was better in J and W pouches compared with S pouches.

Adult↗

PubMed1994

Straight ileo-anal anastomosis with myectomy as an alternative to ileal pouch-anal anastomosis in restorative proctocolectomy.

Restorative proctocolectomy with various types of reservoir is widely used in the elective surgery of ulcerative colitis and familial adenomatous polyposis. Both, advantages and disadvantages of this procedure are well known and documented. Straight ileo-anal anastomosis (IAA) yields unsatisfactory clinical results due to the lack of storage capacity of the distal ileum and the frequency of bowel movements related to high pressure ileal waves. In an attempt to create an alternative to the above procedures, we have performed a straight ileo-anal anastomosis with two rectangular (10 cm x 1 cm) myectomies down to 2 cm, above the anastomotic line. The two myectomies are spaced at 120 degrees to each other and to the mesenteric border of the ileal loop. The rationale of this approach is to reduce the peristaltic drive of the ileum by weakening the muscular wall. This study presents the results in three patients operated on with this new method in the last year.

Adult↗

PubMed1994

Gynaecological and sexual function related to anatomical changes in the female pelvis after restorative proctocolectomy.

Restorative proctocolectomy with an ileal pouch-anal anastomosis preserves anal sphincters, the normal route of defaecation and the normal body image and it has been suggested that the procedure might be associated with less gynaecological and sexual problems than conventional proctocolectomy. To shed further light on this subject 60 female patients were invited to participate in a study comprising a detailed interview, examination by a gynaecologist and investigation with hysterosalpingography and vaginography. Twenty-one women with a mean follow-up of 38 months after surgery agreed to participate. Their gynaecological state was considered normal although one woman complained of vaginal discharge. Five women experienced occasional dyspareunia and 2 patients had to take special precautions to avoid bowel leaks at intercourse. While the position of the vagina and uterus in the pelvis appeared normal, hysterosalpingography disclosed bilateral occlusion of the fallopian tubes in 2 and unilateral occlusion in another 9 patients with tubes adhering to the bottom of the lesser pelvis in 10 of the patients. Only one out of 14 patients succeeded in trying to conceive during the follow-up period. Among the remaining 39 women not specially studied 5 out of 14 had conceived after the operation.

Adult↗

PubMed2004

Salvage surgery after restorative proctocolectomy.

Restorative proctocolectomy is now the elective surgical procedure of choice for most patients with ulcerative colitis or familial adenomatous polyposis. There are four causes of failure including acute and chronic sepsis, poor function for mechanical or functional reasons, mucosal inflammation (including pouchitis and retained rectal mucosa) and neoplastic transformation. Failure rates themselves range from 5% to nearly 20%. Followed over a period of 20 years, the failure rate can be summarised approximately as 5% at five years, 10% at ten years and 15% at 15 years.

Digestive System Surgical Procedures↗

PubMed1994

An analysis of 50 cases of restorative proctocolectomy.

Restorative proctocolectomy with ileal pouch-anal anastomosis is clearly the operation of choice for ulcerative colitis and polyposis coli. Not so clear is the best way to perform this operation. The technique used at the University of Pittsburgh is described. Utilising a meticulous mucosectomy with the patient in a prone jack-knife position, the ileal pouch-anal anastomosis was successfully performed in a series of 50 consecutive patients which included six with orthotopic liver graft, nine with a prior Hartmann procedure, ten with fulminant colitis and six with cancer. All patients were fully continent of stools, and except for one, had a good functional result. Complications were minor and included pelvic sepsis (n = 2), ileostomy-related complications (n = 6) and pouchitis (n = 7).

Adenomatous Polyposis Coli↗

PubMed2000

Laparoscopic restorative proctocolectomy: case-matched comparative study with open restorative proctocolectomy.

PURPOSE: A laparoscopic approach to restorative proctocolectomy is new and has not been compared recently with the traditional open procedure. By using prospectively gathered data, laparoscopic and open restorative proctocolectomy procedures in mucosal ulcerative colitis and familial adenomatous polyposis patients were compared by using a case-matched design. METHODS: Forty patients, composing 20 consecutive laparoscopic cases (13 mucosal ulcerative colitis, 7 familial adenomatous polyposis), were matched for age, gender, and body mass index with 20 open cases (13 mucosal ulcerative colitis, 7 familial adenomatous polyposis) performed during the same time period. Mucosal ulcerative colitis patients were also matched for severity of disease by using hemoglobin and albumin levels, whole blood count, and steroid dependency. A loop ileostomy was made in 12 of 13 laparoscopic mucosal ulcerative colitis patients, all open mucosal ulcerative colitis patients, and no familial adenomatous polyposis patients. RESULTS: The median age was 25 (range, 9-61) years. There were no intraoperative complications in either group and no conversions in the laparoscopic group. The operative times (median, range) were significantly longer in laparoscopic cases (330, 180-480 minutes) vs. open cases (230, 180-300 minutes), P < 0.001. Bowel function returned more quickly in laparoscopic cases (2, 1-8 days) vs. open cases (4, 1-13 days), P = 0.03; and the length of stay was shorter in laparoscopic cases (7, 4-14 days) vs. open cases (8, 6-17 days), P = 0.02. For diverted patients, the median length of stay was reduced by two days in laparoscopic cases (6, 4-14 days) vs. open cases (8, 6-17 days), P = 0.01. Complications occurred in 4 of 20 laparoscopic patients (3 obstruction/ileus and 1 pelvic abscess) and 5 of 20 open patients (2 obstruction and ileus, 1 each anastomotic leak and abscess, peptic ulceration, and episode of dehydration). CONCLUSIONS: Return of intestinal function and length of stay are reduced in the laparoscopic group compared with open group. A laparoscopic approach to restorative proctocolectomy has the potential of becoming an appealing alternative to conventional restorative proctocolectomy surgery.

Adenomatous Polyposis Coli↗

PubMed2004

Results of surgical removal of the pouch after failed restorative proctocolectomy.

PURPOSE: Restorative proctocolectomy is the elective surgical procedure of choice for ulcerative colitis and familial adenomatous polyposis. Most patients have a satisfactory outcome, but at ten years 15 percent or more will have failed, needing indefinite defunctioning or excision of the pouch. There is little information on the morbidity of pouch excision. The study was designed to present the early results of surgical removal of the pouch after failed restorative proctocolectomy with reference to the indications and intermediate complications, particularly of the perineal wound. METHODS: Between 1977 and 2002, 996 patients underwent a restorative proctocolectomy at our hospital and 245 patients were referred for potential salvage. The pouch was excised in 58 and 10 patients respectively. There were 40 females and 28 males (median age, 34 (14-65) years) including 47 with ulcerative colitis, 10 with Crohn's disease, and 11 with familial adenomatous polyposis. The median follow-up was 79 (range, 3-312) months from excision. RESULTS: There was one (1.4 percent) postoperative death. The overall morbidity rate was 62.3 percent (immediate 30 days (25 percent), late (53.7 percent)). Thirty-six patients (53.7 percent) were readmitted on 67 occasions for a late complication. The risk of readmission from the time of pouch excision was 38 and 58 percent at one and five years, respectively. Surgical treatment was required during 48 of these readmissions. A persistent perineal sinus was the most common late complication. The perineal wound was not healed at 6 months in 27 patients (40 percent) and at 12 months in 7 patients (10 percent). No factor, including age at the time of pouch excision, gender, indication for excision, or final histologic diagnosis, was associated with an unhealed perineal wound. Two males (7 percent) had impotence. One female suffered from short-bowel syndrome with the need of permanent parenteral nutrition. The median overall hospital stay for all admissions was 20 (range, 8-220) days. CONCLUSIONS: Pouch excision is associated with high morbidity. Perineal wound-delayed healing is the commonest late complication and often requires further surgery.

Adenomatous Polyposis Coli↗

PubMed2005

Laparoscopic restorative proctocolectomy.

BACKGROUND: Restorative proctocolectomy is increasingly being performed using minimally invasive surgery. In published series laparoscopically assisted techniques have usually included a suprapubic incision to enable major parts of the operation to be done openly. METHODS: Fifty consecutive patients with familial adenomatous polyposis or ulcerative colitis underwent laparoscopic restorative proctocolectomy using only a small perumbilical incision of 4 cm or less for vascular dissection and pouch formation; all other steps were performed entirely laparoscopically. Logistic regression was used for statistical analysis. RESULTS: In four patients (8 per cent) the operation was converted to an open procedure. The diagnosis of ulcerative colitis was associated with a higher overall rate of complications (P = 0.011), and an increased body mass index (BMI) with a higher rate of major complications (P = 0.050). The occurrence of wound infection was related to the diagnosis of ulcerative colitis (P = 0.049). Conversion resulted in greater blood loss (P = 0.004), but not in a higher complication rate. No patient required a blood transfusion. Patients with an increased BMI and those taking immunosuppressive therapy had a longer hospital stay (P = 0.043). CONCLUSION: Laparoscopic restorative proctocolectomy is technically feasible. Patients with ulcerative colitis and increased BMI have a higher risk of complications. This minimally invasive technique may reduce the need for perioperative blood transfusion.

Adenomatous Polyposis Coli↗

PubMed2000

A study of plasma immunoglobulins profile in connection with restorative proctocolectomy.

BACKGROUND: Restorative proctocolectomy is an operative procedure that in principle means proctocolectomy, preserving the anal sphincters and construction of an ileal pouch which is sutured to the dentate line. The method is used mostly in case of surgical treatment of ulcerative colitis or familial polyposis coli. The procedure means different manipulations with the distal ileum that may influence the function of gut-associated lymphoid tissues, a major subdivision of the immune system. AIM: The aim of the present investigation was to study the plasma concentration of immunoglobulins in connection with the restorative proctocolectomy operation. METHODS: Forty five patients received an ileoanal pouch (IAP) because of ulcerative colitis. Twenty seven patients were males and 18 females. The mean age was 34 (range 18-55) years. Twenty six patients were first operated on emergency by subtotal colectomy with terminal ileostomy. In a second operation, the rectum was excised and an ileoanal pouch and a loop ileostomy that diverted the bowel content from the distal ileum was performed. Eighteen elective patients had their colectomy performed at the same time as the pouch operation. As a last procedure the diverting loop ileostomy was closed and thereby the distal ileum and the ileoanal pouch was put into function. Blood samples for plasma immunoglobulin analyses was collected from the patients before the colectomy, after colectomy with terminal ileostomy before construction of the pouch, during the period with pouches prior to loop ileostomy closure and 12 months after its closure. Immunoglobulins in plasma were determined by nephelometry method. The data was analyzed statistically by ANOVA and linear regression analysis. RESULTS: There was a significant difference preoperatively, in plasma immunoglobulin G (P-IgG) between the patients who were operated on electively compared to the emergency patients (p < 0.03). This was the only significant difference between values for the emergency and elective groups throughout the study. In the emergency patients after colectomy and with terminal ileostomy plasma immunoglobulin A (P-IgA) and immunoglobulin A (P-IgM) concentrations in plasma had increased significantly compared to preoperative (p < 0.03) and (p < 0.002) respectively. During the time with loop ileostomy plasma IgM was still found to be significantly elevated (p < 0.02) compared to the level before colectomy. In the electively operated patients plasma IgA and IgM were significantly increased after colectomy and pouch construction during the time with loop ileostomy compared to preoperatively (p < 0.04) and (p < 0.0004). After 12 months with functional pouches the plasma immunoglobulins in both groups were similar to the elective patients preoperatively. CONCLUSION: The immunoglobulins IgG, IgA and IgM were studied in connection with restorative proctocolectomy. Preoperatively, IgG was found to be significantly lower in emergency compared to elective patients. The difference is probably due to increased losses and impaired production of IgG in the acute phase of ulcerative colitis. IgA and IgM were found to increase significantly after colectomy and construction of an ileostomy but how these measures were responsible for the changes could not be determined in the present study. Twelve months after loop ileostomy closure there were no longer any significant changes of the immunoglobulins compared to elective patients with ulcerative colitis preoperatively.

Adolescent↗

PubMed1994

Transanal mucosectomy. Ileal pouch advancement for anorectal dysplasia or inflammation after restorative proctocolectomy.

PURPOSE: Restorative proctocolectomy has gained increasing popularity in the surgical treatment of ulcerative colitis. However, symptomatic proctitis in an excessively long anorectal stump or high-grade dysplasia within the retained anorectal mucosa can pose challenging problems. A corrective operation for these problems is described. METHODS: A sphincter-preserving perineal approach to mobilize the pouch was described. It allows excision of the inflamed or dysplastic-retained anorectal mucosa, followed by pouch advancement and a neoileoanal anastomosis. RESULTS: The technique was successfully performed in two patients, one with symptomatic "proctitis" and another with high-grade dysplasia in the anorectal mucosa after a previously stapled ileoanal (distal rectal) anastomosis. CONCLUSIONS: This report illustrates the relative ease and safety of delayed mucosectomy via a perineal approach, provided that the initially stapled anastomosis is within 3 cm to 4 cm of the dentate line. This technique also obviates the need for complex abdominopelvic surgery after previous restorative proctocolectomy.

Adult↗

PubMed1997

Urinary changes in patients following restorative proctocolectomy.

Following restorative proctocolectomy, the physiological function of the large intestine to absorb water and electrolytes is lost. Therefore, the kidney plays an important role in adjusting the water and electrolyte balance along with the ileal pouch. The reservoir function of the ileal pouch, however, may affect the functional adaptation of urinary changes. To observe the functional adaptation of urinary changes in ileal pouch patients, their changes in urinary output and electrolytes were investigated. Urinary output, pH, and electrolytes were all measured at 1 month, 6 months, and 1 year after surgery in patients with a J-pouch (n = 30) and compared with those in patients who had undergone ileostomy (n = 11) and healthy controls (n = 22). In the patients with a J-pouch, the urinary output, pH, and sodium concentration were significantly lower than those of the controls at 1 month after the operation. However, they gradually increased to near the control values at 1 year. In patients with an ileostomy, the urinary output, pH, and sodium concentration were lower than the control values up to 1 year postoperatively, but the urinary uric acid concentration was higher than that in the controls in both groups up to 1 year. The patients who had persistent aciduria were given a citrate mixture (3g/day), which effectively normalized the aciduria and also possibly prevented urinary uric acid stone formation.

Adult↗

PubMed2006

Serum biochemical evaluation of patients with functional pouches ten to 20 years after restorative proctocolectomy.

BACKGROUND: Restorative proctocolectomy with an ileal pouch-anal anastomosis is a surgical treatment of choice for ulcerative colitis and familial adenomatous polyposis (FAP). Pouchitis is a significant enigmatic morbidity. In the long-term, these patients, we anticipated, would experience biochemical profiling alterations after years of retaining functionally acceptable pouches. This pilot study was aimed at assessing results of essential biochemical variables more than 10 years after surgery. METHODS: The investigation was carried out in 91 patients; 39 were women. Eight-eight had ulcerative colitis, while three had FAPs. The hand-sewn ileal reservoirs after mucoso-proctocolectomy were 66 S and 25 J. The analyses were compared short-term vs long-term. Patients were investigated and were their own control. RESULTS: Long-term, incidence of acute and chronic pouchitis was 2 and 13%. Eleven and 4% of patients had hypomagnesaemia and hypocalcaemia. Mean levels were significantly enhanced (p<0.01 and p<0.0002). Hypomagnesaemia corresponded to episodes of pouchitis and was corrected with oral magnesium and antibiotics. Hypoferric anaemia was diagnosed in 7% and treated with oral iron tablets. Chronic pouchitis and recurrent pouch mucosa bleeding were the cause. Hypohemoglobinemia and hypocyanocobalaminemia were noted in 5% and 5%, respectively. Erythrocyte sedimentation rate and white blood cells were supra-normal in 13 and 10%, which corresponded with pouchitis. A significant (p<0.03) steady rise of mean serum immunoglobulin G without correlation to pouchitis was noted. CONCLUSION: Long-term functional results did not deteriorate. Pouchitis was a significant enigmatic morbidity. Severe or chronic pouchitis complicated hypoferric and vitamin B(12) anemia and hypomagnesaemia.

Blood Proteins↗

PubMed2002

Portal vein thrombi after restorative proctocolectomy.

BACKGROUND: Restorative proctocolectomy (RP) has been the surgical procedure of choice for surgical management of mucosal ulcerative colitis since 1978. This study was undertaken to investigate the clinical presentation and implications of portal vein thrombi (PVT). METHODS: We reviewed all patients undergoing RP in our institution in the 4 years from January 1997 to December 2000. As the diagnosis of PVT was made on computed tomography (CT) scan in all cases, we confined our incidence estimate to those patients having an abdominal CT scan postoperatively. All scans were reviewed by an experienced radiologist. Patient demographics, symptoms, and clinical course were recorded. RESULTS: A total of 702 patients underwent RP, of whom 94 had a CT scan within the postoperative period. PVT was diagnosed in 42 of the 94 patients (45%). PVT was diagnosed at initial reading of the scan in 11 patients, and on review in 31. The indications for CT scan included abdominal pain, fever, leukocytosis, and delayed bowel function. Septic complications of RP caused these symptoms and signs in 45 patients, 20 of whom had PVT. Twenty-two patients were found to have had PVT without evidence of any septic source. CONCLUSION: PVT can be found in a high proportion of patients undergoing abdominal CT scan after RP. It is often associated with pain, fever, nausea vomiting, tenderness, and leukocytosis. This study shows that PVT subtle enough to go undiagnosed has no serious consequences, even when not treated. Also, patients treated with anticoagulation recover completely.

Adult↗

PubMed1998

[Complications and late outcome of restorative proctocolectomy].

The restorative proctocolectomy with ileoanal pouch is a sophisticated operative procedure with considerable postoperative complications. The main problems are postoperative ileus (11%), anastomotic stricture (9%), local septic complications (13%) and pouchitis (29%). A variety of other complications also occur. Most of the problems can be successfully managed by conservative or surgical treatment. In only 2.5% (n = 15/593) was final pouch extirpation necessary. Postoperative function showed elevated stool frequency (6 per day) and slightly compromised stool continence. Most patients confirm good quality of life.

Adenomatous Polyposis Coli↗

PubMed2002

Staple-line ulcer in the ileal reservoir following restorative proctocolectomy.

PURPOSE: Following restorative proctocolectomy, seven cases with staple line ulcer around the pouch anal anastomosis and/or staple line in the ileal pouch were experienced. Their clinical, endoscopical characteristics were analyzed. METHODS: The patients noted anal bleeding following restorative proctocolectomy were examined with colonofiberscopy and histological study was conducted. RESULTS: Staple line ulcer was seens in seven cases (2.3%, 7/304). The onset was immediate or within 2 months postoperatively in 5 cases. Bleeding occurred in all the patients and lower abdominal pain, anal pain, increased bowel movements and anal fissure were seen frequently. Ulcers were linear along the staple line and there were no cases complicated by simultaneous pouchitis. Most of the patients responded to treatments with metronidazol, 5-ASA, and topical or oral steroids, although one patient required ligation of bleeding ulcer and two complicated perianal excoriation required ileostomy. CONCLUSION: Staple line ulcer should be recognized as different complication to pouchitis.

Adenomatous Polyposis Coli↗

PubMed2003

Risk of dysplasia in the columnar cuff after stapled restorative proctocolectomy.

BACKGROUND: Stapled restorative proctocolectomy (SRP) for ulcerative colitis retains a 'cuff' of columnar epithelium, which carries a risk of undergoing malignant change. The risk of neoplastic transformation was studied in a series of patients who underwent SRP for ulcerative colitis. METHODS: One hundred and thirty-five patients who underwent SRP for ulcerative colitis between 1988 and 1998 were followed up by cuff surveillance biopsy. The median follow-up was 56 (range 12-145) months and the median time since diagnosis of ulcerative colitis was 8.8 (range 2-32) years. RESULTS: The cuff biopsies showed no dysplasia or carcinoma. The accuracy of obtaining cuff mucosa in the biopsy was 65 per cent. Chronic inflammation was present in 94 per cent of cuff biopsies. CONCLUSION: This study shows no evidence of either dysplasia or carcinoma in the columnar cuff mucosa, up to 12 years after pouch formation. This suggests that cuff surveillance in the first decade after SRP, in the absence of dysplasia or carcinoma in the original colectomy specimen, may be unnecessary. Regular cuff surveillance biopsies after SRP should continue for patients with high-grade dysplasia or carcinoma in the original resection specimen.

Cell Transformation, Neoplastic↗