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Lo SW, Dharia I, Sriranganathan D, Kayal M, Barnes EL, Segal JP. The prevalence of pouch fistulas in ulcerative colitis following restorative proctocolectomy: a systematic review and meta-analysis. Intest Res 2025; 23:56-64. [PMID: 39118327 PMCID: PMC11834361 DOI: 10.5217/ir.2024.00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/17/2024] [Accepted: 05/09/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND/AIMS One complication of restorative proctocolectomy with ileo-anal pouch anastomosis is fistula formation in the pouch. Fistulas can be associated with significant morbidity and pouch failure. We conducted a systematic review with meta- analysis to try and understand the prevalence of pouch fistulas in patients with ulcerative colitis following restorative proctocolectomy. METHODS The Embase, Embase Classic, and PubMed databases were searched between January 1979 and April 2022. Studies were included if there were cross-sectional, case-controlled, population-based or cohort studies reporting on prevalence of pouch fistulas in ulcerative colitis. Studies had to report the number of patients with pouch fistulas using either clinical, endoscopic, or radiological diagnosis in an adult population. RESULTS Thirty-three studies screened met the inclusion criteria. The pooled prevalence of developing at least 1 fistula was 0.05 (95% confidence interval [CI], 0.04-0.07). The pooled prevalence of pouch failure in patients with pouch fistula was found to be 0.24 (95% CI, 0.19-0.30). The pooled prevalence of developing a pouch fistula at 3 years, 5 years and more than 5 years was 0.04 (95% CI, 0.02-0.07), 0.05 (95% CI, 0.02-0.07), and 0.05 (95% CI, 0.02-0.10), respectively. CONCLUSIONS This is the first systematic review and meta-analysis to report the prevalence of pouch fistula. It also provides a pooled prevalence of pouch failure in these patients. These results can help to shape future guidelines, power future studies, and help counsel patients.
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Affiliation(s)
- Sheng Wei Lo
- Department of Gastroenterology, Northern Hospital, Epping, Australia
| | - Ishaan Dharia
- Department of Gastroenterology, The Mount Sinai Hospital, New York, NY, USA
| | - Danujan Sriranganathan
- Department of Gastroenterology, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Maia Kayal
- Department of Gastroenterology, The Mount Sinai Hospital, New York, NY, USA
| | - Edward L. Barnes
- Division of Gastroenterology and Hepatology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jonathan P. Segal
- Department of Gastroenterology, Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine, The University of Melbourne, Parkville, Australia
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Syal G, Mishkin DS, Banty A, Lee S, Fontelera N, Hampton M, Ziring D, Fleshner PR, Melmed GY. Effectiveness of Oral Tofacitinib in Chronic Pouchitis: A Prospective, Open-Label Pilot Study. Inflamm Bowel Dis 2024; 30:1907-1910. [PMID: 37898112 DOI: 10.1093/ibd/izad191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Indexed: 10/30/2023]
Affiliation(s)
- Gaurav Syal
- Division of Gastroenterology and Hepatology, University of California San Diego, San Diego, CA, USA
| | | | - Andrea Banty
- Karsh Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Susie Lee
- Karsh Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Norma Fontelera
- Karsh Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Melissa Hampton
- Karsh Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - David Ziring
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Phillip R Fleshner
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Gil Y Melmed
- Karsh Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Abstract
BACKGROUND Patients with ulcerative colitis refractory to medication or familial adenomatous polyposis may require ileal pouch-anal anastomosis after a colectomy. IPAA is generally well tolerated. However, patients can experience posttreatment complications, including pouch strictures and leaks. Medical therapy has a limited role in mechanical fibrotic strictures, whereas surgery is invasive and costly. In the past few decades, endoscopic therapies have provided a less invasive and less costly intervention for pouch strictures and leaks. OBJECTIVE This systematic literature review aimed to describe the status of advancements in endoscopic therapy for pouch leaks and strictures. DATA SOURCES The sources used were PubMed and Cochrane databases. STUDY SELECTION Studies between January 1990 and January 2022, in any language, were included. Articles regarding surgical management or pouches other than adult ileal pouch-anal anastomosis were excluded. INTERVENTIONS Endoscopic management of acute and chronic leaks and strictures ileal pouch-anal anastomosis was included. MAIN OUTCOME MEASURES Successful management (including persistent leak or stricture, pouch failure, subsequent endoscopy, or surgery) was measured. RESULTS Sixty-one studies were included in this review, including 4 meta-analyses or systematic reviews, 11 reviews, 17 cohort studies, and 18 case series. LIMITATIONS The limitations include qualitative review of all study types, with no randomized controlled studies available. CONCLUSION Ileal pouch-anal anastomosis leaks are various in configuration, and endoscopic therapies have included clipping leaks at the tip of the "J" as well as endoscopic sinusotomy. Endoscopic therapies for pouch strictures have included endoscopic balloon dilation, endoscopic stricturotomy, and endoscopic stricturoplasty, which are now considered first-line therapies for pouch strictures. Endoscopic balloon dilation has shown safety and efficacy in single, short, and straight strictures and endoscopic stricturotomy for refractory long, fibrotic, anastomotic strictures. Endoscopic therapies can delay or prevent invasive surgeries. Key tenets of successful endoscopic therapy include patient and lesion candidacy, an experienced endoscopist, and adequate rescue surgery plans.
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Appropriateness of Medical and Surgical Treatments for Chronic Pouchitis Using RAND/UCLA Appropriateness Methodology. Dig Dis Sci 2022; 67:4687-4694. [PMID: 35006492 DOI: 10.1007/s10620-021-07362-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 12/06/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS The treatment of chronic pouchitis remains a challenge due to the paucity of high-quality studies. We aimed to provide guidance for clinicians on the appropriateness of medical and surgical treatments in chronic pouchitis. METHODS Appropriateness of medical and surgical treatments in patients with chronic pouchitis was considered in 16 scenarios incorporating presence/absence of four variables: pouchitis symptoms, response to antibiotics, significant prepouch ileitis, and Crohn's disease (CD)-like complications (i.e., stricture or fistula). Appropriateness of permanent ileostomy in patients refractory to medical treatments was considered in eight additional scenarios. Using the RAND/UCLA appropriateness method, international IBD expert panelists rated appropriateness of treatments in each scenario on a 1-9 scale. RESULTS Chronic antibiotic therapy was rated appropriate only in asymptomatic antibiotic-dependent patients with no CD-like complications and inappropriate in all other scenarios. Ileal-release budesonide was rated appropriate in 6/16 scenarios including patients with significant prepouch ileitis but no CD-like complications. Probiotics were considered either inappropriate (14/16) or uncertain (2/16). Biologic therapy was considered appropriate in most scenarios (14/16) and uncertain in situations where significant prepouch ileitis or CD-like complications were absent (2/16). In patients who are refractory to all medications, permanent ileostomy was considered appropriate in all scenarios (7/8) except in asymptomatic patients with no CD-like complications. CONCLUSIONS In the presence of significant prepouch ileitis or CD-like complications, chronic antibiotics and probiotics are inappropriate. Biologics are appropriate in all patients except in asymptomatic patients with no evidence of complications. Permanent ileostomy is appropriate in most medically refractory patients.
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A systematic review and meta-analysis of the outcome of ileal pouch-anal anastomosis in patients with ulcerative colitis versus patients with familial adenomatous polyposis. Tech Coloproctol 2022; 26:691-705. [PMID: 35357610 DOI: 10.1007/s10151-022-02617-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/16/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Ileal pouch-anal anastomosis (IPAA) is commonly used to restore gastrointestinal continuity after surgical treatment of mucosal ulcerative colitis (MUC) and familial adenomatous polyposis (FAP). The aim of the present systematic review was to compare the outcomes of patients with MUC and patients with FAP who underwent IPAA. METHODS A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant systematic review was performed. PubMed, Scopus, and Web of Science were searched through December 2021. Cohort and randomized studies were eligible for inclusion if they directly compared patients with MUC and FAP who underwent IPAA. The main outcome measures were pouch failure, complications, and need for pouch excision or revision. ROBINS-I tool was used to assess the risk of bias across the studies. A random-effect meta-analysis was conducted. RESULTS Twenty-three studies (9200 patients) were included in this meta-analysis. Seven thousand nine hundred fifty (86.4%) had MUC and 1250 (13.6%) had FAP. The median age of patients was 33.1 years. The male to female ratio was 1.4:1. MUC had higher odds of pouchitis (OR 3.9, 95% CI 2.8-5.4, p < 0.001), stricture (OR 1.82, 95% CI 1.25-2.65, p = 0.002), fistula (OR 1.74, 95% CI 1.18-2.54, p = 0.004), and total complications (OR 1.89, 95% CI 1.3-2.77, p < 0.001) as compared to FAP. Both groups had similar odds of pelvic sepsis, leakage, pouch failure, excision, revision, and fecal incontinence. CONCLUSIONS Although patients with MUC undergoing IPAA may be at a higher risk of developing complications, particularly pouchitis, stricture, and fistula; the ultimate and functional outcome of the pouch is similar to patients with FAP. Pouch failure, excision and revision were similar in the two groups.
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MacDonald S, Au S, Thornton M, Macdonald A. Complications and functional outcomes after ileo-anal pouch excision-a systematic review of 14 retrospective observational studies. Int J Colorectal Dis 2021; 36:677-687. [PMID: 33471205 DOI: 10.1007/s00384-021-03838-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE The ileo-anal pouch (IAP) has been the gold standard procedure for maintenance of bowel continuity after panproctocolectomy for ulcerative colitis, familial adenomatous polyposis or hereditary non-polyposis colorectal cancer. However, the IAP has an estimated failure rate of 13% at 10 years post-procedure (Tulchinsky et al., Ann Surg 238(2):229-34, 2003), which can result in pouch excision (P.E.). This systematic review aims to synthesise all the available studies reporting post-operative outcomes of P.E. and its impact on patient quality of life (QoL), when available, which have not previously been summarised. METHODS PubMed, Embase, Medline and the Cochrane library databases were searched with terms 'Pouch AND excision' OR 'Pouch AND removal' OR 'Pouch AND remove' OR 'IAP AND excision'. All studies reporting post-operative morbidity, mortality or functional outcomes in patients who had P.E. were included. Studies with < 5 patients, non-English studies and conference abstracts were excluded. RESULTS 14 studies comprising 1601 patients were included. Overall complications varied from 18 to 63% with the most common being persistent perineal sinus (9-40%) or surgical site infection (wound-2 to 30%; intra-abdominal collection-3 to 24%). The mortality rate was between 0.58 and 1.4%. QoL is generally lower in P.E. patients compared to the normal population across various QoL measures and P.E. patients often had urinary and sexual dysfunction post-operatively. CONCLUSIONS There is a substantial incidence of complications after P.E.; however, there is no evidence describing QoL pre- and post-P.E. Further longitudinal research comparing QoL in patients undergoing P.E. and other treatment options such as indefinite diversion is required to definitively assess QoL post-procedure.
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Affiliation(s)
- S MacDonald
- Department of Surgery, University Hospital Monklands, Airdrie, North Lanarkshire, Scotland, ML6 0JS, UK.
| | - S Au
- Department of Surgery, University Hospital Monklands, Airdrie, North Lanarkshire, Scotland, ML6 0JS, UK
| | - M Thornton
- Department of Surgery, Wishaw General Hospital, 50 Netherton St., Wishaw, Scotland, ML2 0DP, UK
| | - A Macdonald
- Department of Surgery, University Hospital Monklands, Airdrie, North Lanarkshire, Scotland, ML6 0JS, UK
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Feinberg AE, Lavryk O, Aiello A, Hull TL, Steele SR, Stocchi L, Holubar SD. Conditional Survival After IPAA for Ulcerative and Indeterminate Colitis: Does Long-term Pouch Survival Improve or Worsen With Time? Dis Colon Rectum 2020; 63:927-933. [PMID: 32243352 DOI: 10.1097/dcr.0000000000001629] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Risk factors for pouch survival may or may not have a linear relationship with pouch loss over time. Conditional survival is a method to describe these nonlinear time-to-event relationships by reporting the expected survival at various time points. OBJECTIVE The aim of this study was to calculate conditional pouch survival based on occurrence of risk factors for pouch loss. DESIGN This was a retrospective study from an institutional database. SETTINGS The study was conducted at the Cleveland Clinic Foundation. PATIENTS Patients with ulcerative or indeterminate colitis who underwent index IPAA construction between 1986 and 2016 were included. MAIN OUTCOME MEASURES Patients were stratified based on postoperative anastomotic leak, abscess, or fistula occurrence. The Kaplan-Meier method with conditional survival was used to estimate overall and cause-specific survival at 10 years. RESULTS A total of 3468 patients underwent IPAA during the study period. The overall 10-year pouch survival rate was 0.94 (95% CI, 0.93-0.95), and after 1 year the conditional pouch survival increased to 0.95 (95% CI, 0.94-0.96), after 3 years to 0.97 (95% CI, 0.96-0.98), and after 5 years to 0.98 (95% CI, 0.98-0.99). A total of 122 patients (3.5%) developed anastomotic leak, and the 10-year IPAA survival in patients with leak was 0.85 (95% CI, 0.77-0.93). In this group, after 1 year of pouch survival, the conditional pouch survival increased to 0.89 (95% CI, 0.82-0.96) and after 3 years to 0.98 (95% CI, 0.94-1.00). A similar pattern was seen for IPAA with postoperative abscess. The conditional survival curve was stable over time for patients with a fistula. LIMITATIONS This was a retrospective, single-institution study. CONCLUSIONS Overall conditional pouch survival improved over time for patients with postoperative anastomotic leak and abscess. These novel findings can be useful to counsel patients regarding expectations for long-term pouch survival even if they develop leaks and abscesses. See Video Abstract at http://links.lww.com/DCR/B217. SUPERVIVENCIA CONDICIONAL DESPUÉS DE ANASTOMOSIS CON BOLSA ÍLEO ANAL, PARA COLITIS ULCERATIVA E INDETERMINADA: ¿LA SOBREVIDA DE LA BOLSA A LARGO PLAZO, MEJORA O EMPEORA CON EL TIEMPO?: Los factores de riesgo para la sobrevida de la bolsa, pueden o no tener una relación lineal con la pérdida de la bolsa y con el tiempo. La supervivencia condicional es un método para describir estas relaciones no lineales de tiempo, hasta el evento informando la supervivencia esperada en varios puntos de tiempo.El objetivo de este estudio fue calcular la supervivencia condicional de la bolsa, en función de aparición de factores de riesgo para la pérdida de bolsa.Estudio retrospectivo de una base de datos institucional.Cleveland Clinic Foundation.Pacientes con colitis ulcerativa o indeterminada, sometidos a una anastomosis de bolsa íleo anal, de 1986 a 2016.Los pacientes fueron estratificados en función de la fuga anastomótica postoperatoria, absceso o aparición de fístula. El método de Kaplan Meier con supervivencia condicional, se utilizó para estimar la supervivencia general y la causa específica a los 10 años.Un total de 3.468 pacientes fueron sometidos a anastomosis ileal con bolsa anal durante el período de estudio. La tasa de supervivencia global de la bolsa a 10 años, fue de 0,94 (0,93 a 0,95), y después de 1 año, la supervivencia condicional de la bolsa aumentó a 0,95 (0,94 a 0,96), después de 3 años a 0,97 (0,96 a 0,98) y después de 5 años a 0.98 (0.98 - 0.99). Un total de 122 (3,5%) pacientes desarrollaron fuga anastomótica, y la supervivencia de la anastomosis de bolsa íleo anal a 10 años en pacientes con fuga fue de 0,85 (IC del 95%: 0,77 a 0,93). En este grupo, después de 1 año de supervivencia de la bolsa, la supervivencia condicional de la bolsa aumentó a 0,89 (IC del 95%: 0,82 a 0,96), y después de 3 años a 0,98 (IC del 95%: 0,94 a 1). Se observó un patrón similar para la anastomosis de bolsa íleo anal con absceso postoperatorio. La curva de supervivencia condicional fue estable en el tiempo para los pacientes con una fístula.Estudio retrospectivo, de una sola institución.La supervivencia condicional global de la bolsa, mejoró con el tiempo para pacientes con fuga anastomótica postoperatoria y absceso. Estos nuevos hallazgos pueden ser útiles para aconsejar a los pacientes con respecto a las expectativas de supervivencia de la bolsa a largo plazo, incluso si desarrollan fugas y abscesos. Consulte Video Resumen http://links.lww.com/DCR/B217. (Traducción-Dr Fidel Ruiz Healy).
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Affiliation(s)
- Adina E Feinberg
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Olga Lavryk
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Alexandra Aiello
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Tracy L Hull
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Scott R Steele
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Luca Stocchi
- Division of Colon & Rectal Surgery, Mayo Clinic, Jacksonville, Florida
| | - Stefan D Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
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Impact on Fertility After Failure of Restorative Proctocolectomy in Men and Women With Ulcerative Colitis: A 17-Year Cohort Study. Dis Colon Rectum 2020; 63:816-822. [PMID: 32149783 DOI: 10.1097/dcr.0000000000001640] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Impact of restorative proctocolectomy failure on fertility has not been studied and is greatly relevant. OBJECTIVE The purpose of this study was to evaluate the impact of restorative proctocolectomy failure on birth rate in women and men, along with in vitro fertilization incidence and success. DESIGN This was a retrospective registry-based cohort study over 17 years. SETTINGS Records for parenting a child were cross-linked with patient records. In women, in vitro fertilization records were cross-linked. All data were prospectively registered. PATIENTS Patients of fertile age with ulcerative colitis between 1994 and 2010 were identified in Danish national databases. Patients with restorative proctocolectomy and restorative proctocolectomy failure were identified as subgroups. MAIN OUTCOME MEASURES Birth rate ratios and in vitro fertilization incidence and success were measured. RESULTS We included 11,939 women and 13,569 men with ulcerative colitis. A total of 711 women and 730 men had restorative proctocolectomy; 114 women and 90 men had failure. Birth rate in women with failure was significantly reduced compared with women without (birth rate ratio = 0.50 (95% CI, 0.29-0.82)). In men with failure, birth rate tended to be lower compared with men without (birth rate ratio = 0.74 (95% CI, 0.51-1.05)). In vitro fertilization incidence was similar with and without failure (HRs adjusted for age at start of follow-up = 0.98 (95% CI, 0.58-1.67]). In vitro fertilization success was significantly lower with failure compared with ulcerative colitis (OR adjusted for age at start of follow-up = 0.36 (95% CI, 0.4-0.92)). LIMITATIONS Information on patients leading up to restorative proctocolectomy failure is lacking. Failure patients may have had children during a period with pouch function. Therefore, the impact of failure may be underestimated. CONCLUSIONS Restorative proctocolectomy failure impairs birth rate, primarily in women. Although in vitro fertilization incidence is similar in women with and without failure, the likelihood of giving birth after in vitro fertilization is reduced. See Video Abstract at http://links.lww.com/DCR/B202. IMPACTO SOBRE LA FERTILIDAD DESPUéS DEL FRACASO DE LA PROCTOCOLECTOMíA RESTAURADORA EN HOMBRES Y MUJERES CON COLITIS ULCEROSA: UN ESTUDIO DE COHORTE DE 17 AñOS: No se ha estudiado el impacto de la falla de la proctocolectomía restauradora en la fertilidad y es muy relevante.Evaluar el impacto del fracaso de la proctocolectomía restauradora en la tasa de natalidad en mujeres y hombres, junto con la incidencia y el éxito de la fertilización in vitro.Estudio de cohorte retrospectivo basado en el registro de más de 17 años.Los registros de crianza de un niño se cruzaron con los registros de pacientes. En las mujeres, los registros de fertilización in vitro se cruzarón. Todos los datos se regitraron de forma prospectiva.Los pacientes de edad fértil con colitis ulcerosa entre 1994-2010 fueron identificados en las bases de datos nacionales danesas. Los pacientes con proctocolectomía restauradora y fracaso de la proctocolectomía restauradora se identificaron como subgrupos.Tasas de natalidad e incidencia y éxito de la fertilización in vitro.Se incluyeron 11939 mujeres y 13569 hombres con colitis ulcerosa. 711 mujeres y 730 hombres tuvieron proctocolectomía restauradora; 114 mujeres y 90 hombres tuvieron fracaso. La tasa de natalidad en las mujeres con fracaso se redujo significativamente en comparación con las mujeres sin fracaso (tasa de natalidad: 0,50; IC del 95% [0,29; 0,82]). En los hombres con fracaso, la tasa de natalidad tendió a ser más baja en comparación con los hombres sin fracaso (tasa de natalidad: 0,74; IC del 95% [0,51; 1,05]). La incidencia de fertilización in vitro fue similar con y sin falla (aHR: 0.98, IC 95% [0.58; 1.67]). El éxito de la fertilización in vitro fue significativamente menor con el fracaso en comparación con la colitis ulcerosa (aOR: 0.36 IC 95% [0.4; 0.92]).Falta información sobre los pacientes que conducen al fracaso de la proctocolectomía restauradora. Los pacientes con fracaso pueden haber tenido hijos durante un período con función de bolsa. Por lo tanto, el impacto del fracaso puede ser subestimado.El fracaso de la proctocolectomía restauradora afecta la tasa de natalidad, principalmente en mujeres. Aunque la incidencia de la fertilización in vitro es similar en las mujeres con y sin fracaso, la probabilidad de dar a luz después de la fertilización in vitro se reduce. Consulte Video Resumen en http://links.lww.com/DCR/B202. (Traducción-Dr Gonzalo Hagerman).
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Ileal pouch-anal anastomosis for ulcerative colitis: long-term outcomes and trends over time in a low-volume institution. Ir J Med Sci 2020; 190:143-149. [PMID: 32472241 DOI: 10.1007/s11845-020-02262-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 05/16/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Ileal pouch-anal anastomosis (IPAA) can restore bowel continuity for patients with ulcerative colitis (UC) who have needed total colectomy with end ileostomy. Internationally, this surgery is recommended for centralisation focussing reflection on Irish outcomes. METHODS Retrospective study examining patient outcomes after IPAA in our institution over a 15-year period using data from inflammatory bowel disease database, HIPE codes and clinical charts review between January 2002 and January 2018. Cohorts were analysed overall and in 5-year cohorts as well as by access modality of pouch operation. Contextualising Irish data were identified from published literature review. RESULTS Thirty-four patients (average age 34.8, 21/64% male) had IPAA for UC locally with 64-month mean follow-up. Overall laparoscopic procedure rate was 39.4% (85% 2013-17) being associated with lower lengths of stay (10.6 ± 8 vs 12.7 ± 6.5 days open access). The mean total duration of ileostomy was 27.3 ± 22.5 months, being longest most recently and with an open index procedure. Overall pouchitis affected 53% (n = 18) with rates at 1, 5, 10 and 15 years being 17.6%, 38.2, 50.0% and 52.9%, respectively. Pouch failure rates at 1, 5 and 10 years were 2.9%, 11.8% and 17.6%. Outcomes were similar with other centres publishing from Ireland although none met modern criteria for high-volume practice. CONCLUSIONS Overall outcomes and practice in this study are consistent with previously published studies on IPAA nationally and internationally. While acceptable, the opportunity from surgical centre collaboration outside of the National Cancer and Acute Surgery Strategies is to offer still better outcomes for our patients.
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Helavirta I, Lehto K, Huhtala H, Hyöty M, Collin P, Aitola P. Pouch failures following restorative proctocolectomy in ulcerative colitis. Int J Colorectal Dis 2020; 35:2027-2033. [PMID: 32592093 PMCID: PMC7541371 DOI: 10.1007/s00384-020-03680-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Restorative proctocolectomy (RPC) is the most common operation in ulcerative colitis. Nevertheless, permanent ileostomy will sometimes be unavoidable. The aim was to evaluate the reasons for pouch failure and early morbidity after pouch excision. METHODS The number and the reasons for pouch failures were analysed in patients undergoing RPC 1985-2016. RESULTS Out of 491 RPC patients, 53 experienced pouch failure (10 women, 43 men); 52 out of 53 underwent pouch excision. The cumulative risk for excision at 5, 10 and 20 years was 5.6, 9.4 and 15.5%, respectively. The reasons for failure included septic events such as fistula in 12 (23%), chronic pouchitis in 11 (21%) and leakage in 8 (15%) patients. Functional reasons for pouch failure were recorded as poor function in 16 (30%), incontinence in 12 (23%) and stricture in 12 (23%) patients. Multiple causes for pouch failure were recorded for individual patients. Seven cases of Crohn's disease were found among the failure cases: two before pouch excision and five after. Altogether, 15 Crohn's disease diagnoses were set in the RPC cohort, giving a percentage of 47% of pouch failure in this disorder. A complication occurred in 23 (44%) patients within 30 days after surgery; 16 were mild (Clavien-Dindo grades I-II). CONCLUSIONS Eleven percent of RPC patients suffered pouch failure: more men than women. The reasons were multiple. Crohn's disease created a risk of failure, but a half of these patients maintained the pouch. Morbidity after pouch excision was moderate, but in most cases slight.
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Affiliation(s)
- Ilona Helavirta
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Teiskontie 35, FI-33521, Tampere, Finland.
| | - Kirsi Lehto
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Teiskontie 35, FI-33521, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, P.O. Box 100, FI-33014, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, FI-33014, Tampere, Finland
| | - Marja Hyöty
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Teiskontie 35, FI-33521, Tampere, Finland
| | - Pekka Collin
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Teiskontie 35, FI-33521, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, P.O. Box 100, FI-33014, Tampere, Finland
| | - Petri Aitola
- Faculty of Medicine and Health Technology, Tampere University, P.O. Box 100, FI-33014, Tampere, Finland
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Die J, Ocaña J, Abadía P, García JC, Moreno I, Pina JD, Rodrígez G, Devesa JM. Experience, complications and prognostic factors of the ileoanal pouch in ulcerative colitis: An observational study. Cir Esp 2019; 98:64-71. [PMID: 31735363 DOI: 10.1016/j.ciresp.2019.09.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 09/12/2019] [Accepted: 09/20/2019] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Ileoanal pouch following restorative proctocolectomy is the treatment for ulcerative colitis after failed medical treatment. Our main aim was to evaluate early and late morbidity associated with restorative proctocolectomy. The secondary aim was to assess risk factors for pouch failure. METHODS A retrospective, observational, single-center study was performed. Patients who had undergone restorative proctocolectomy for a preoperative diagnosis of ulcerative colitis from 1983-2015 were included. Early (<30 days) and late (>30 days) adverse events were analyzed. Pouch failure was defined as the need for pouch excision or when ileostomy closure could not be performed. Univariate and multivariate analyses were performed to assess pouch failure risk factors. RESULTS The study included 139 patients. One patient subsequently died in the early postoperative period. Mean follow-up was 23 years. Manual anastomoses were performed in 54 patients (39%). Early adverse events were found in 44 patients (32%), 15 of which (11%) had anastomotic fistula. Late adverse events were found in 90 patients (65%), and pouch-related fistulae (29%) were the most commonly found in this group. Pouch failure was identified in 42 patients (32%). In the multivariate analysis, age >50 years (p<0.01; HR: 5.55), handsewn anastomosis (p<0.01; HR: 3.78), pouch-vaginal (p=0.02; HR: 2.86), pelvic (p<0.01; HR: 5.17) and cutaneous p=0.01; HR: 3.01) fistulae were the main pouch failure risk factors. CONCLUSION Restorative proctocolectomy for a preoperative diagnosis of ulcerative colitis has high morbidity rates. Long-term outcomes could be improved if risk factors for failure are avoided.
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Affiliation(s)
- Javier Die
- Unidad de Coloproctología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Juan Ocaña
- Unidad de Coloproctología, Hospital Universitario Ramón y Cajal, Madrid, España.
| | - Pedro Abadía
- Unidad de Coloproctología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Juan Carlos García
- Unidad de Coloproctología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Irene Moreno
- Unidad de Coloproctología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Juan Diego Pina
- Unidad de Coloproctología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Gloria Rodrígez
- Unidad de Coloproctología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - José Manuel Devesa
- Unidad de Coloproctología, Hospital Universitario Ramón y Cajal, Madrid, España
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12
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Mark-Christensen A, Erichsen R, Brandsborg S, Pachler FR, Nørager CB, Johansen N, Pachler JH, Thorlacius-Ussing O, Kjaer MD, Qvist N, Preisler L, Hillingsø J, Rosenberg J, Laurberg S. Pouch failures following ileal pouch-anal anastomosis for ulcerative colitis. Colorectal Dis 2018; 20:44-52. [PMID: 28667683 DOI: 10.1111/codi.13802] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 06/28/2017] [Indexed: 12/12/2022]
Abstract
AIM Ileal pouch-anal anastomosis is a procedure offered to patients with ulcerative colitis who opt for restoration of bowel continuity. The aim of this study was to determine the risk of pouch failure and ascertain the risk factors associated with failure. METHOD The study included 1991 patients with ulcerative colitis who underwent ileal pouch-anal anastomosis in Denmark in the period 1980-2013. Pouch failure was defined as excision of the pouch or presence of an unreversed stoma within 1 year after its creation. We used Cox proportional hazards regression to explore the association between pouch failure and age, gender, synchronous colectomy, primary faecal diversion, annual hospital volume (very low, 1-5 cases per year; low, 6-10; intermediate 11-20; high > 20), calendar year, laparoscopy and primary sclerosing cholangitis. RESULTS Over a median 11.4 years, 295 failures occurred, corresponding to 5-, 10- and 20-year cumulative risks of 9.1%, 12.1% and 18.2%, respectively. The risk of failure was higher for women [adjusted hazard ratio (aHR) 1.39, 95% CI 1.10-1.75]. Primary non-diversion (aHR 1.63, 95% CI 1.11-2.41) and a low hospital volume (aHR, very low volume vs high volume 2.30, 95% CI 1.26-4.20) were also associated with a higher risk of failure. The risk of failure was not associated with calendar year, primary sclerosing cholangitis, synchronous colectomy or laparoscopy. CONCLUSION In a cohort of patients from Denmark (where pouch surgery is centralized) with ulcerative colitis and ileal pouch-anal anastomosis, women had a higher risk of pouch failure. Of modifiable factors, low hospital volume and non-diversion were associated with a higher risk of pouch failure.
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Affiliation(s)
- A Mark-Christensen
- Department of Surgery, Section of Coloproctology, Aarhus University Hospital, Aarhus, Denmark
| | - R Erichsen
- Department of Surgery, Section of Coloproctology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - S Brandsborg
- Department of Surgery, Section of Coloproctology, Aarhus University Hospital, Aarhus, Denmark
| | - F R Pachler
- Department of Surgery, Section of Coloproctology, Aarhus University Hospital, Aarhus, Denmark
| | - C B Nørager
- Department of Surgery, Section of Coloproctology, Aarhus University Hospital, Aarhus, Denmark
| | - N Johansen
- Department of Surgery, Lillebaelt Hospital Kolding, Kolding, Denmark
| | - J H Pachler
- Gastroenterology Unit, Hvidovre Hospital, Hvidovre, Denmark
| | - O Thorlacius-Ussing
- Department of Surgical Gastroenterology A, Aalborg Hospital, Aalborg, Denmark
| | - M D Kjaer
- Department of Surgery A, Odense University Hospital, Odense, Denmark
| | - N Qvist
- Department of Surgery A, Odense University Hospital, Odense, Denmark
| | - L Preisler
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - J Hillingsø
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - J Rosenberg
- Department of Surgery, Herlev Hospital, Herlev, Denmark
| | - S Laurberg
- Department of Surgery, Section of Coloproctology, Aarhus University Hospital, Aarhus, Denmark
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13
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Lightner AL, Dattani S, Dozois EJ, Moncrief SB, Pemberton JH, Mathis KL. Pouch excision: indications and outcomes. Colorectal Dis 2017; 19:912-916. [PMID: 28387059 DOI: 10.1111/codi.13673] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 01/09/2017] [Indexed: 12/13/2022]
Abstract
AIM Restorative proctocolectomy with ileal-pouch anal anastomosis is the procedure of choice for ulcerative colitis. Unfortunately, up to 10% of pouches will fail, requiring either reconstruction or excision. While several series have reported on the aetiology of pouch failure, no study to date has focused on the postoperative complications associated with pouch excision. METHODS Patients who had excision of ileoanal reservoir with ileostomy (CPT code 45136) were included. Data abstracted included preoperative, operative and postoperative variables. A Kaplan-Meier curve of pouch survival was performed. RESULTS In all, 147 patients met the inclusion criteria for the study. The median age of patients was 47 years (73 women), and 132 had a diagnosis of ulcerative colitis at the time of colectomy. The most common indications for pouch excision were sepsis (n = 46; 31%) and Crohn's disease (n = 37; 25%). 84 (57%) patients experienced short-term (< 30 days) postoperative complications, the most common of which was a surgical site infection (n = 32; 21%); 55 (37%) patients had long-term complications (> 30 days) postoperatively, the most common of which was a return to the operating room (n = 19; 13%) largely for perineal wounds. Thirty-day mortality was zero. 4.8%, 47.6%, 65.3% and 84.4% of patients had undergone pouch excision by 1, 5, 10 and 20 years from the time of pouch construction, respectively. CONCLUSIONS Pouch excision has a high rate of both short- and long-term postoperative complications. Patients should be appropriately counselled to set expectations accordingly. In view of these findings we suggest that this operation should ideally be performed at a high volume centre with the availability of a multidisciplinary surgical team.
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Affiliation(s)
- A L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - S Dattani
- Division of General Surgery, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - E J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - S B Moncrief
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - J H Pemberton
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - K L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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14
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Baek SJ, Lightner AL, Boostrom SY, Mathis KL, Cima RR, Pemberton JH, Larson DW, Dozois EJ. Functional Outcomes Following Laparoscopic Ileal Pouch-Anal Anastomosis in Patients with Chronic Ulcerative Colitis: Long-Term Follow-up of a Case-Matched Study. J Gastrointest Surg 2017; 21:1304-1308. [PMID: 28470559 DOI: 10.1007/s11605-017-3411-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 03/23/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic ileal pouch-anal anastomosis (L-IPAA) has been increasingly adopted over the last decade due to short-term patient-related benefits. Several studies have shown L-IPAA to be equivalent to open IPAA in terms of safety and short-term outcomes. However, few L-IPAA studies have examined long-term functional outcomes. We aimed to evaluate the long-term functional outcomes of L-IPAA as compared to open IPAA. METHODS A previous case-matched cohort study at our institution compared short-term outcomes between L-IPAA and open IPAA from 1998 to 2004. For this study, we selected all patients from this case-matched cohort study with chronic ulcerative colitis (CUC) who had follow-up functional data of greater than 1 year. Functional data was obtained through prospective surveys, which were sent annually to all IPAA patients postoperatively. RESULTS One hundred and forty-nine patients (58 L-IPAA, 91 open IPAA) with a median 8-year duration of follow-up were identified. There were no differences in demographics and long-term surgical outcomes between groups. Stapled anastomosis was more common in the laparoscopic group (91.4 versus 54.9%, p < 0.001). Stool frequency during daytime (>6 stools, L-IPAA 32.8%, open 49.4%, p = 0.048) and nighttime (>2 stools, L-IPAA 13.8%, open 30.6%; p = 0.024) was significantly lower in the L-IPAA group. Ability to differentiate gas from stool was not different (p = 0.13). Rate of complete continence was similar in L-IPAA and open groups (L-IPAA 36.2%, open 21.8%, p = 0.060). There was no difference in use of medication to control stools, perianal skin irritation, voiding difficulty, sexual problems, and occupational change between groups. Subgroup analysis to evaluate for any group differences attributable to anastomotic technique demonstrated only that stapled anastomoses lead to more perianal skin irritation in the L-IPAA group (L-IPAA = 60.4% versus open IPAA = 38.8%; p = 0.031). CONCLUSION Overall, L-IPAA has comparable functional results to the open approach with slightly lower daytime and nighttime stool frequency. This difference may be attributed to a greater number of stapled anastomoses performed in the laparoscopic cohort.
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Affiliation(s)
- Se-Jin Baek
- Division of Colon and Rectal Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | | | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - John H Pemberton
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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15
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Hatimi H, Kumar S, Chandra A, Gupta V. Pouch pseudoaneurysm: a rare cause of recurrent haemorrhage following ileal pouch-anal anastomosis. BMJ Case Rep 2017; 2017:bcr-2016-216208. [PMID: 28108437 DOI: 10.1136/bcr-2016-216208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Bleeding following restorative proctocolectomy for chronic ulcerative colitis is an uncommon complication. Usually bleeding occurs from the ileal pouch-anal anastomotic site in the early postoperative period. Significant pouch bleeding in the late postoperative course is rarely encountered. A mesenteric artery pseudoaneurysm along the ileal pouch staple line may be a cause of late-presenting massive per-rectal bleed. Although a rare phenomenon, it must be considered to be a differential in such a situation.
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Affiliation(s)
- Hunaid Hatimi
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Saket Kumar
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Abhijit Chandra
- Department of Surgical Gastroenterology, KGMC, CSMMU, Lucknow, Uttar Pradesh, India
| | - Vishal Gupta
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, Uttar Pradesh, India
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16
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Outcome and functional prognosis of pelvic sepsis after ileal pouch-anal anastomosis in patients with ulcerative colitis. Surg Today 2016; 47:301-306. [DOI: 10.1007/s00595-016-1430-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 06/06/2016] [Indexed: 10/20/2022]
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17
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Value of histopathology for predicting the post-operative complications of ileo-anal anastomosis (J-pouch) procedure in children with refractory ulcerative colitis. Pathology 2016; 48:330-5. [DOI: 10.1016/j.pathol.2016.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 12/26/2015] [Accepted: 01/03/2016] [Indexed: 01/27/2023]
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Histologic inflammatory activity of the rectal margin as a predictor of postoperative complication in ileoanal anastomosis (J-pouch) procedure in children with refractory ulcerative colitis. J Pediatr Surg 2016; 51:783-5. [PMID: 26921936 DOI: 10.1016/j.jpedsurg.2016.02.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 02/07/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Postoperative complication from the ileoanal anastomosis (J-pouch) procedure for surgical management of refractory ulcerative colitis (UC) increases the risk of pouch dysfunction. The purpose of this study was to determine if histologic inflammatory activity of the rectal margin is an independent predictor of complication after controlling for other variables. METHODS A retrospective chart review was performed to identify all pediatric patients with UC who underwent a J-pouch procedure between 1995 and 2014. Univariate and multivariate regression analyses were performed on the following variables: age at surgery, body mass index, comorbidities, time between colectomy and pouch, mucosectomy, protective ileostomy status, length of pouch, and histologic inflammatory activity in the intestinal epithelium of the rectal margin. RESULTS Nineteen complicated and 23 uncomplicated cases were included. Histologic inflammatory activity was significantly higher among the complicated group (9.3±3.1 vs. 4.1±3.1, p=0.02). No significant difference was found regarding other variables. In a multivariate regression, histologic inflammation of the rectal margin remained significantly associated with complication (p=0.04) after adjusting for other factors. CONCLUSION After controlling for potential confounders, histologic inflammatory activity at the rectal margin was found to be a significant predictor of postoperative complication in the J-pouch procedure for refractory UC. LEVEL OF EVIDENCE 2b.
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19
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Byrne CM, Rooney PS. Ileo-anal pouch excision: A review of indications and outcomes. World J Surg Proced 2015; 5:119-126. [DOI: 10.5412/wjsp.v5.i1.119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Revised: 01/12/2015] [Accepted: 02/02/2015] [Indexed: 02/06/2023] Open
Abstract
Restorative proctocolectomy (RP) is the surgical treatment of choice for ulcerative colitis (UC) and patients with familial adenomatous polyposis (FAP). A devastating complication for both patient and surgeon is failure of the pouch that requires excision. There is currently no single paper in the literature that consolidates the indications for ileo-anal pouch excision and the subsequent outcomes following this procedure. A literature search was carried out to identify articles on RP and ileal pouch-anal anastomosis. The main search terms used were “RP”; “ileal pouch-anal anastomosis” or “ileal reservoir” or “ileal pouch”; “failure of ileal pouch-anal anastomosis” and “excision of ileal pouch-anal anastomosis”. The search was completed using electronic databases MEDLINE, PubMed and EMBASE from 1975 to June 2014. Characteristics of patients with pouch failure differ between institutions. Reported overall excision rates of the pouches vary and in this review ranged from 0.93% to 12.8%. Age and lower institutional volume (less than 3.3 cases) were independent predictors of pouch failure; however surgeon case load was not. The main reasons identified for excision are sepsis (early cause), Crohn’s disease and poor functional outcomes (both late causes). Pouch cancers in UC and FAP are still rare but 135 cases exist in the literature. The most common complication following excision is persistent perineal sinus. The decision to excise a pouch should not be taken lightly and an awareness of the technical pitfalls and complications that can occur should be fully appreciated.
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Abstract
After colorectal and anorectal interventions for chronic inflammatory bowel diseases, specific complications can occur.In Crohn's disease these complications mainly occur after proctocolectomy. Pelvic sepsis can be prevented by omentoplasty with fixation inside the pelvis. A persisting sepsis of the sacral cavity can be treated primarily by dissection of the anal sphincter which ensures better drainage. In cases of chronic sacral sepsis, transposition of the gracilis muscle is a further effective option. Early recurrence of a transsphincteric anal fistula should be treated by reinsertion of a silicon seton drainage.Complications after restorative proctocolectomy are frequent and manifold (35%). The main acute complications are anastomotic leakage and pelvic sepsis. Therapy consists of transperineal drainage of the abscess with simultaneous transanal drainage. Late complications due to technical and septic reasons are still a relevant problem even 36 years after introduction of this operative technique. A consistent approach with detailed diagnostic and surgical therapy results in a 75% rescue rate of ileoanal pouches.
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21
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Odze RD. A contemporary and critical appraisal of 'indeterminate colitis'. Mod Pathol 2015; 28 Suppl 1:S30-46. [PMID: 25560598 DOI: 10.1038/modpathol.2014.131] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 07/29/2014] [Accepted: 07/30/2014] [Indexed: 02/06/2023]
Abstract
Distinguishing ulcerative colitis (UC) from Crohn's disease (CD) is normally based on evaluation of a variety of clinical, radiologic, serologic and pathologic findings, the latter in biopsy and/or resection specimens. Unfortunately, some patients with IBD show overlapping pathologic features of UC and CD, which makes definite distinction between these two disorders difficult or even impossible. In most instances of uncertainty, the patient shows clinical and pathologic features of UC, but in addition, the patient's colon resection specimen reveals one or more CD-like features. In this setting, a diagnosis of indeterminate colitis (IC) is often rendered. IC is not a distinct disease entity, and, thus, it has no diagnostic criteria. The most common causes of uncertainty in IBD pathology that may lead to a diagnosis of IC in a colon resection specimen includes the presence of fulminant (severe and toxic) colitis, insufficient radiologic, endoscopic, or pathologic information (including analysis of prior biopsies) on the patient, failure to utilize major diagnostic criteria as hard evidence in favor of CD, failure to recognize unusual variants of UC and CD that may mimic each other, failure to recognize non-IBD mimics and other superimposed diseases that cause unusual pathologic features in a resection specimen, an attempt to distinguish UC from CD in mucosal biopsies of the colon and ileum, or an attempt to change the patients diagnosis (of UC or CD) based on pouch or diversion-related complications. Details of each of these causes of uncertainty are discussed, in detail, in this review article. A diagnosis of IC should never be made clinically or by pathologists based on evaluation of pre-resection colonic mucosal biopsies. Ultimately, the majority of indeterminate cases represent UC, and, thus, most of these patient can be treated safely with a colectomy combined with an ileal pouch anal anastomosis procedure.
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Affiliation(s)
- Robert D Odze
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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22
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Bressenot A, Cahn V, Danese S, Peyrin-Biroulet L. Microscopic features of colorectal neoplasia in inflammatory bowel diseases. World J Gastroenterol 2014; 20:3164-3172. [PMID: 24696602 PMCID: PMC3964388 DOI: 10.3748/wjg.v20.i12.3164] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 10/28/2013] [Accepted: 01/20/2014] [Indexed: 02/06/2023] Open
Abstract
The risk of developing dysplasia leading to colorectal cancer (CRC) is increased in both ulcerative colitis and Crohn’s disease. The prognosis of CRC may be poorer in patients with inflammatory bowel disease (IBD) than in those without IBD. Most CRCs, in general, develop from a dysplastic precursor lesion. The interpretation by the pathologist of the biopsy will guide decision making in clinical practice: colonoscopic surveillance or surgical management. This review summarizes features of dysplasia (or intraepithelial neoplasia) with macroscopic and microscopic characteristics. From an endoscopic (gross) point of view, dysplasia may be classified as flat or elevated (raised); from a histological point of view, dysplasia is separated into 3 distinct categories: negative for dysplasia, indefinite for dysplasia, and positive for dysplasia with low- or high-grade dysplasia. The morphologic criteria for dysplasia are based on a combination of cytologic (nuclear and cytoplasmic) and architectural aberrations of the crypt epithelium. Immunohistochemical and molecular markers for dysplasia are reviewed and may help with dysplasia diagnosis, although diagnosis is essentially based on morphological criteria. The clinical, epidemiologic, and pathologic characteristics of IBD-related cancers are, in many aspects, different from those that occur sporadically in the general population. Herein, we summarize macroscopic and microscopic features of IBD-related colorectal carcinoma.
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23
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Francone TD, Champagne B. Considerations and complications in patients undergoing ileal pouch anal anastomosis. Surg Clin North Am 2013. [PMID: 23177068 DOI: 10.1016/j.suc.2012.09.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Total proctocolectomy with ileal pouch anal anastomosis (IPAA) preserves fecal continence as an alternative to permanent end ileostomy in select patients with ulcerative colitis and familial adenomatous polyposis. The procedure is technically demanding, and surgical complications may arise. This article outlines both the early and late complications that can occur after IPAA, as well as the workup and management of these potentially morbid conditions.
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Affiliation(s)
- Todd D Francone
- Department of Colon and Rectal Surgery, University of Rochester Medical Center, Rochester, NY 14642, USA.
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Prediction of late-onset pouch failure in patients with restorative proctocolectomy with a nomogram. J Crohns Colitis 2012; 6:198-206. [PMID: 22325174 DOI: 10.1016/j.crohns.2011.08.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 08/11/2011] [Accepted: 08/11/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND A proportion of UC patients with restorative proctocolectomy and IPAA develop pouch failure. Accurate risk assessment is critical for making proper evaluation and treatment. Information on factors that may reliably predict pouch failure for the patients requiring referral to a specialized care unit is minimal. AIM We sought to develop and internally validate a nomogram for the prediction of late-onset pouch failure. METHODS The study cohort included all eligible UC patients with restorative proctocolectomy and IPAA at the subspecialty Pouchitis Clinic from 2002 to 2009. Inclusion criteria were patients having: 1) inflammatory bowel disease; 2) ileal pouches; and 3) regular follow-up at the Pouchitis Clinic. Demographic and clinical variables were prospectively collected. Multivariable accelerated failure time regression model was developed to predict pouch failure defined as pouch excision or permanent diversion. Discrimination and calibration of the model were assessed following bootstrapping methods for correcting optimism, and the model was presented as a nomogram. RESULTS A total of 921 patients were included for the model. The mean age for this cohort was 45.5 years old. The mean follow-up at the Pouchitis Clinic was 5.8 years. Kaplan-Meier analysis showed that the probabilities for pouch retention are 0.939, 0.916 and 0.907 at 3, 5 and 7 years, respectively. The predictor variables which were included in the nomogram were smoking, duration of the pouch, baseline pouch diagnosis, and pre- and post-op use of biologics. The concordance index was 0.824. The nomogram seemed well calibrated based on the calibration curve. CONCLUSIONS The nomogram model appeared to predict late-onset pouch failure reasonably well with satisfactory concordance index and calibration curve. The nomogram is readily applicable for clinical practice in pouch patients.
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Abstract
BACKGROUND The risks and benefits of pouch excision and end ileostomy creation when compared to the alternative option of a permanent diversion with the pouch left in situ when restoration of intestinal continuity is not pursued for patients who develop pouch failure after IPAA have not been well characterized. OBJECTIVE This study aimed to compare the early and long-term outcomes after permanent diversion with the pouch left in situ vs pouch excision with end ileostomy creation for pouch failure. DESIGN This study is a retrospective review of prospectively gathered data. SETTINGS This investigation was conducted at a tertiary center. PATIENTS Patients with pouch failure who underwent a permanent ileostomy with the pouch left in situ and those who underwent pouch excision were included in the study. MAIN OUTCOME MEASURES The primary outcomes measured were the perioperative outcomes and quality of life using the pouch and Short Form 12 questionnaires. RESULTS One hundred thirty-six patients with pouch failure underwent either pouch left in situ (n = 31) or pouch excision (n = 105). Age (p = 0.72), sex (p = 0.72), ASA score (p = 0.22), BMI (p = 0.83), disease duration (p = 0.74), time to surgery for pouch failure (p = 0.053), diagnosis at pouch failure (p = 0.18), and follow-up (p = 0.76) were similar. The predominant reason for pouch failure was septic complications in 15 (48.4%) patients in the pouch left in situ group and 39 (37.1%) patients in the pouch excision group (p = 0.3). Thirty-day complications, including prolonged ileus (p = 0.59), pelvic abscess (p = 1.0), wound infection (p = 1.0), and bowel obstruction (p = 1.0), were similar. At the most recent follow-up (median, 9.9 y), quality of life (p = 0.005) and health (p = 0.008), current energy level (p = 0.026), Cleveland Global Quality of Life score (p = 0.005), and Short Form 12 mental (p = 0.004) and physical (p = 0.014) component scales were significantly higher after pouch excision than after pouch left in situ. Urinary and sexual function was similar between the groups. Anal pain (n = 4) and seepage with pad use (n = 8) were the predominant concerns of the pouch left in situ group on long-term follow-up. None of the 18 patients with pouch in situ, for whom information relating to long-term pouch surveillance was available, developed dysplasia or cancer. LIMITATIONS This study was limited by its retrospective nature. CONCLUSIONS Although technically more challenging, pouch excision, rather than pouch left in situ, is the preferable option for patients who develop pouch failure and are not candidates for restoration of intestinal continuity. Because pouch left in situ was not associated with neoplasia, this option is a reasonable intermediate or long-term alternative when pouch excision is not feasible or advisable.
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Liu ZX, Deroche T, Remzi FH, Hammel JP, Fazio VW, Ni RZ, Goldblum JR, Shen B. Transmural inflammation is not pathognomonic for Crohn's disease of the pouch. Surg Endosc 2011; 25:3509-17. [PMID: 21660630 DOI: 10.1007/s00464-011-1749-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Accepted: 03/22/2011] [Indexed: 01/01/2023]
Abstract
BACKGROUND Transmural inflammation shown by imaging and histology has been considered a hallmark of Crohn's disease (CD). However, the diagnostic and prognostic value of this feature in CD of the pouch has not been evaluated. This study aimed to evaluate the clinical utility of transmural inflammation in patients with ileal pouch-anal anastomosis (IPAA) using in vivo optical coherence tomography (OCT) and histopathology. METHODS All the patients were recruited from the subspecialty Pouchitis Clinic. The study consisted of two parts: (1) a prospective study with in vivo through-the-scope OCT for the evaluation of transmural disease in patients with normal or diseased pouches and (2) a retrospective pathology re-review for transmural inflammation in excised pouch specimens of CD and chronic pouchitis. RESULTS This prospective OCT study enrolled 53 patients: 11 (20.8%) with normal pouches or irritable pouch syndrome, 10 (18.9%) with acute pouchitis, 11 (20.8%) with chronic antibiotic-refractory pouchitis (CARP), and 21 (39.6%) with CD of the pouch. Transmural inflammation, characterized by the loss of layered structure on OCT, was detected in 16 patients (30.2%): 4 with chronic pouchitis and 12 with CD of the pouch. None of the patients with normal pouches, irritable pouch syndrome, or acute pouchitis had transmural disease shown on OCT. Of the 26 patients with pouch failure who had pouch excision, the surgical specimens showed transmural disease in 30% of the CARP patients (3/10) and 12.5% (2/16) of those with CD of the pouch. CONCLUSIONS Transmural disease in the setting of IPAA is not pathognomonic of CD. Transmural inflammation shown by imaging or histopathology was seen in both CD and CARP. Transmural inflammation of the pouch appeared to be associated with poor pouch outcome.
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Affiliation(s)
- Zhao-xiu Liu
- Department of Gastroenterology, Affiliated Hospital of Nantong University, Jiangsu, China
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How I do it: the stapled ileal J pouch at restorative proctocolectomy. Tech Coloproctol 2011; 15:451-4. [PMID: 21984050 DOI: 10.1007/s10151-011-0757-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 08/28/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ileal pouch-anal anastomosis (IPAA) following proctocolectomy is the preferred option for patients with medically refractory ulcerative colitis, indeterminate colitis, and familial adenomatous polyposis. However, it remains a procedure associated with morbidity and mortality. Pelvic sepsis, pouch fistulae, and anastomotic dehiscence predispose to pouch failure. We report our experience with an adaptation for the formation of the stapled ileal J pouch using the GIA™ 100 stapling device (Covidien, Mansfield, Massachusetts, USA). When creating the J pouch, we remove the bevelled plastic protector from the thin fork of the stapling device, allowing the staple line to be completed to the tip of the stapled efferent limb of the pouch, thereby minimizing potential blind ending in the efferent limb and injury to the transverse staple line. METHODS Patients undergoing elective IPAA at our institution over a 5-year period using this adapted stapling technique for creation of the ileal J pouch were reviewed. Data were collected from a prospectively maintained inflammatory bowel disease database, theater records, and patient chart review. RESULTS Forty-one patients underwent IPAA using this technique at our institution during the study period. Postoperative morbidity was encountered in 11 of 41 patients including pelvic sepsis, pouch fistulae, anastomotic stricture, or leak. There was no morbidity observed related to a blind efferent limb or transverse staple line disruption. No mortality was observed in this series. CONCLUSION Maximizing the length of the efferent fork of the GIA stapling device can reduce the length of redundant efferent J limb of the ileal J pouch. This may reduce the incidence of torsion, volvulus, distension, fistulae/sinuses, and pelvic sepsis/anastomotic leak following IPAA.
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Abstract
Coloproctectomy with ileo-anal anastomosis (CP-IAA) has been in use for 30 years. This intervention is the standard technique when surgery is indicated for familial adenomatous polyposis (FAP) and for ulcerative colitis (UC). Although the surgery is safe with mortality of less than 1%, it is associated with a morbidity of 18-70%. We thought a literature review about long-term complications would be enlightening. Pouchitis is the most common complication; it occurs in 70% of patients over 20 years follow-up; small bowel obstruction affects 25% of patients and pelvic sepsis occurs in 20-30% within 10 years. CP-IAA can impact the patient's sexual life due to erectile and ejaculatory dysfunction, dyspareunia, and incontinence of stool during sexual intercourse. Nevertheless, patients with long-standing UC describe an overall improvement in their sexual function after surgery. The failure rate varies from 3.5 to 15%; major causes of failure are sepsis, unrecognized Crohn's disease, and poor functional results. Cases of dysplasia and cancer have been reported in the reservoir, but more particularly when there is retained colonic glandular mucosa. The transitional zone should be monitored whenever there are risk factors for colon neoplasia. The relatively high morbidity of CP-IAA should not overshadow the good functional results of this technique.
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Affiliation(s)
- A Beliard
- Service de chirurgie digestive et de cancérologie digestive, groupe hospitalo-universitaire Carémeau, rue du Professeur-Robert-Debré, 30029 Nîmes cedex 9, France
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Abstract
With the advent of restorative proctocolectomy or ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC), not only has there been potential for cure of UC but also patients have enjoyed marked improvements in bowel function, continence, and quality of life. However, IPAA can be complicated by postoperative small bowel obstruction, disease recurrence, and pouch failure secondary to pelvic sepsis, pouch dysfunction, mucosal inflammation, and neoplastic transformation. These may necessitate emergent or expeditious elective reoperation to salvage the pouch and preserve adequate function. Local, transanal, and transabdominal approaches to IPAA salvage are described, and their indications, outcomes, and the clinical parameters that affect the need for salvage are discussed. Pouch excision for failed salvage reoperation is reviewed as well. Relaparotomy is also frequently required for recurrent Crohn's disease (CD), especially given the nature of this as yet incurable illness. Risk factors for CD recurrence are examined, and the various surgical options and margins of resection are evaluated with a focus on bowel-sparing policy. Stricturoplasty, its outcomes, and its importance in recurrent disease are discussed, and segmental resection is compared with more extensive procedures such as total colectomy with ileorectal anastomosis. Lastly, laparoscopy is addressed with respect to its long-term outcomes, effect on surgical recurrence, and its application in the management of recurrent CD.
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Affiliation(s)
- Rowena L Ramirez
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Robotic-assisted laparoscopic "salvage" rectopexy for recurrent ileoanal J-pouch prolapse. Gastroenterol Res Pract 2010; 2010:790462. [PMID: 20414343 PMCID: PMC2855981 DOI: 10.1155/2010/790462] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Accepted: 02/02/2010] [Indexed: 12/13/2022] Open
Abstract
Total restorative proctocolectomy with ileal pouch-anal anastomosis (RP/IPAA) has become the standard of care for the surgical treatment of ulcerative colitis. Despite its correlation with an excellent quality of life and favorable long-term outcomes, RP/IPAA has been associated with several complications. Prolapse of the ileoanal pouch is a rare and debilitating complication that should be considered in the differential diagnosis of pouch failure. Limited data exist regarding the prevalence and treatment of pouch prolapse. We present the case of a recurrent J-pouch prolapse treated with a novel minimally invasive “salvage” approach involving a robotic-assisted laparoscopic rectopexy with mesh.
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Abstract
PURPOSE This study aimed to determine the risk of ileal pouch-anal anastomosis failure and factors predictive of failure overall and in patients with septic complications. METHODS Patients were identified through a prospectively maintained patient registry. All patients registered in the Mount Sinai Hospital Inflammatory Bowel Disease database who had an ileal pouch-anal anastomosis for more than 12 months were included in the study. Pouch failure was defined as ileal pouch-anal anastomosis excision or permanent diversion. Cox proportional hazard models with death as a competing risk were created, modeling time to failure as the outcome of interest for all patients and for the subgroup of patients with septic complications. RESULTS The study included 1,554 patients. One hundred six patients experienced an ileal pouch-anal anastomosis failure (6.8%), 49 (46.2%) of these failures were caused by septic complications. Independent predictors of failure included Crohn's disease (hazard ratio 7.5, 95% confidence interval [4.7, 12.0]) and postoperative sepsis (hazard ratio 6.6, 95% confidence interval [4.4, 9.8]). In the subgroup of patients with failure due to postoperative septic complications, independent predictors of failure were Crohn's disease (hazard ratio 2.7, 95% confidence interval [1.3, 5.7]) and presence of a pouch fistula (hazard ratio 2.6, 95% confidence interval [1.3, 5.2]). CONCLUSION Septic complications are the most common cause of ileal pouch-anal anastomosis failure. Careful patient selection and the prevention of septic complications may decrease the risk of this failure.
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Heriot A, Lynch A. Ileal Pouch Anal Anastomosis: Meta-Analysis and Comparison of Outcomes Between Techniques. SEMINARS IN COLON AND RECTAL SURGERY 2009. [DOI: 10.1053/j.scrs.2009.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Long-term outcome 10 years or more after restorative proctocolectomy and ileal pouch-anal anastomosis in patients with ulcerative colitis. Langenbecks Arch Surg 2009; 395:49-56. [PMID: 19280217 DOI: 10.1007/s00423-009-0479-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2008] [Accepted: 02/24/2009] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of this study was to assess quality of life (QOL) in a long-term follow-up of patients with ulcerative colitis (UC) 10 years and more after ileal pouch-anal anastomosis (IPAA) to correlate these results with pouch function and to assess the long-term pouch failure rate. METHODS In a unicentric study, 294 consecutive patients after IPAA between 1988 and 1996 were identified from a prospective database. QOL was evaluated according to the validated Gastrointestinal Quality of Life Index (GIQLI). RESULTS Overall median follow-up was 11.5 years. Thirty-seven patients experienced pouch failure (12.6%). The rates of ileal pouch success after 5, 10 and 15 years were 92.3%, 88.7% and 84.5%. According to the GIQLI, patients with a functioning pouch achieved a mean score of 107.8, reflecting a decrease of QOL of 10.8% compared to a healthy population. There were significant negative correlations between QOL and an age of >50 years (p < 0.05), pouchitis, perianal inflammation and increased stool frequency (p < 0.0001). CONCLUSIONS QOL and functional results of patients with UC 10 years or more after IPAA were acceptable; however, those were reduced when compared to a healthy population. Pouch failure rate still increases up to 15.5% 15 years after IPAA. This result represents an important issue in providing patients with comprehensive preoperative information.
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Neutrophil-related immunoinflammatory disturbance in steroid-overdosed ulcerative colitis patients. J Gastroenterol 2009; 43:789-97. [PMID: 18958548 DOI: 10.1007/s00535-008-2227-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2007] [Accepted: 06/02/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is some evidence that large preoperative doses of steroids are a causative factor for postoperative higher morbidity in ulcerative colitis (UC) patients. This study aimed to assess steroid-related changes in functional profiles of neutrophils in UC patients to estimate the immunological changes under surgical stress. METHODS Neutrophils were extracted from peripheral blood of 30 UC patients and 30 healthy controls. UC patients whose neutrophils were isolated were divided into two subgroups according to their total preoperative dosage of prednisolone: group H, > or =10,000 mg; group L, <10,000 mg. Expression of neutrophil surface antigens was analyzed and neutrophil phagocytosis was evaluated. Patterns of cell death of neutrophils were evaluated by co-culturing with Escherichia coli. Production of inflammatory mediators in cultured neutrophils was assessed. RESULTS There were no significant differences in the expression rates of TLR4, CD11b, and CD16b on neutrophils (CD15(+) cells) between the two patient groups and controls. There was also no significant difference in neutrophil phagocytosis between the two patient groups and controls. The neutrophil necrosis rate in group H was higher than that in group L and the controls 3 h after exposure to E. coli. Neutrophils from group H released the highest levels of proinflammatory cytokines following interleukin-1beta or lipopolysaccharide stimulation. Neutrophils from group H also released the highest levels of proteolytic enzymes. CONCLUSIONS Steroid-overdosed UC patients may have a functional deficit in neutrophils, which may cause a postsurgical systemic "storm" of inflammatory mediators.
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Rink AD, Radinski I, Vestweber KH. Does mesorectal preservation protect the ileoanal anastomosis after restorative proctocolectomy? J Gastrointest Surg 2009; 13:120-8. [PMID: 18766412 DOI: 10.1007/s11605-008-0665-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2008] [Accepted: 08/08/2008] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND AIMS The technique of rectal dissection during restorative proctocolectomy might influence the rate of septic complications. The aim of this study was to analyze the morbidity of restorative proctocolectomy in a consecutive series of patients who had rectal dissection with complete preservation of the mesorectum. PATIENTS AND METHODS One hundred thirty-one patients who had restorative proctocolectomy for chronic inflammatory bowel disease with handsewn ileopouch-anal anastomosis (IPAA) and preservation of the mesorectal tissue were analyzed by chart reviews and a follow-up investigation at a median of 85 (14-169) months after surgery. RESULTS Only one of 131 patients had a leak from the IPAA, and one patient had a pelvic abscess without evidence of leakage, resulting in 1.5% local septic complications. All other complications including the pouch failure rate (7.6%) and the incidence of both fistula (6.4%) and pouchitis (47.9%) were comparable to the data from the literature. CONCLUSION The low incidence of local septic complications in this series might at least in part result from the preservation of the mesorectum. As most studies do not specify the technique of rectal dissection, this theory cannot be verified by an analysis of the literature and needs further approval by a randomized trial.
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Affiliation(s)
- Andreas D Rink
- Deparment of Surgery, Leverkusen General Hospital, Am Gesundheitspark 11, 51375, Leverkusen, Germany.
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Leal RF, Ayrisono MDLS, Coy CSR, Fagundes JJ, Góes JRN. Complicações imediatas e tardias após cirurgia de reservatório ileal na polipose adenomatosa familiar. ARQUIVOS DE GASTROENTEROLOGIA 2008; 45:106-10. [DOI: 10.1590/s0004-28032008000200003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Accepted: 11/21/2007] [Indexed: 01/26/2023]
Abstract
RACIONAL: A retocolectomia total com confecção de reservatório ileal é cirurgia ideal para o tratamento do cólon e reto dos doentes com polipose adenomatosa familiar, no entanto pode estar associada a complicações no pós-operatório imediato e tardio. OBJETIVO: Estudar as complicações pós-operatórias da cirurgia do reservatório ileal na polipose adenomatosa familiar. MÉTODOS: Estudo retrospectivo de 69 doentes com polipose adenomatosa familiar submetidos a cirurgia de reservatório ileal no período de 1984 a 2006, pelo Grupo de Coloproctologia da Faculdade de Ciências Médicas da Universidade Estadual de Campinas, SP. O seguimento médio pós-operatório foi de 82 (2-280) meses. Dados de interesse: ocorrência de complicações no pós-operatório. RESULTADOS: A morbidade e mortalidade foram de 63,8% e 2,9%, respectivamente. As complicações mais freqüentes foram obstrução intestinal (17,4%), estenose da anastomose (15,9%) e sepse pélvica (10,1%). Outras complicações foram isquemia aguda do reservatório ileal (4,3%), ileíte do reservatório (" pouchitis" ) (2,9%) e fístulas relacionadas ao reservatório (2,9%). CONCLUSÕES: A morbimortalidade foi semelhante à da literatura e aceitável para uma cirurgia complexa como é a do reservatório ileal, realizada em dois tempos operatórios. A obstrução intestinal foi a complicação mais freqüente. Entretanto, isquemia do reservatório, " pouchitis" e sepse pélvica constituíram importantes complicações relacionadas à perda do reservatório ileal.
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Das P, Smith JJ, Lyons AP, Tekkis PP, Clark SK, Nicholls RJ. Assessment of the mucosa of the indefinitely diverted ileo-anal pouch. Colorectal Dis 2008; 10:512-7. [PMID: 18028470 DOI: 10.1111/j.1463-1318.2007.01420.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE One surgical option to treat failure after restorative proctocolectomy (RPC) is indefinite diversion (ID) without excision of the pouch. The study aimed to assess the mucosal morphology of the pouch and ileoanal anastomosis (IAA) over time after ID with particular reference to inflammation, dysplasia and carcinoma. METHOD Patients with ID were identified from the hospital's Ileal Pouch Database. Individuals were invited by mail to attend for flexible pouchoscopy and biopsy from the ileal pouch and immediately distal to the IAA. RESULTS Of 1822 patients on the database, 28 had undergone ID. Of these, 20 patients (18 ulcerative colitis, one familial adenomatous polyposis, one pseudo-obstruction) of median age 42 (18-67) years took part. There were eight males. The median (range) intervals from diagnosis of primary disease, pouch surgery and ID to the time of study were 221 (63-410), 146 (31-314) and 44 (10-159) months respectively. One patient had dysplasia in the original resection specimen. Five patients developed type C changes in the pouch. Of these three were identified between RPC and ID, one developed between ID and the present assessment and one was identified for the first time at the present assessment. No case of dysplasia or cancer was found in any of the biopsies. Rectal mucosa was found in biopsies from the IAA in four patients (three stapled; one handsewn); this was inflamed in three patients. CONCLUSION At a median follow-up of 12 years after RPC and 3.6 years after indefinite diversion no instance of dysplasia or carcinoma in the ileal reservoir or distal to the IAA was found in any of the 20 patients having ID. Type C changes occurred at some time in five (25%) patients, indicating the importance of continued follow up.
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Affiliation(s)
- P Das
- Department of Surgery, St Mark's Hospital, Harrow, Middlesex, UK.
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Byrne CM, Uraiqat AA, Phillips RKS. A systematic stapling defect - a potential cause of 'anastomotic' leak after restorative proctocolectomy. Colorectal Dis 2008; 10:286-8. [PMID: 17949446 DOI: 10.1111/j.1463-1318.2007.01380.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE When constructing ileal-anal pouches with staples, a novel potential cause of anastomotic leak was recently identified at the apex of the pouch. This study was performed to assess this stapling defect. METHOD Careful inspection of the ileal pouch staple lines was made in eight consecutive pouch constructions. Pouch construction was further evaluated using pig small bowel. RESULTS When constructing ileal-anal pouches with staples, a novel potential cause of anastomotic leak was recently identified at the apex of the pouch. This defect was present in seven of eight consecutive ileo-anal J-pouches. It was repaired by direct suturing and no clinical or radiological leaks were identified in these patients. In the pig model, the same defect was found in five of five stapled constructions. It was avoiding in five of five cases by limiting the amount of bowel placed into the stapler on the initial firing. CONCLUSION This defect may be related to stapler design. It can be avoided by using less than the full staple line on the initial firing of the stapler or by using an alternative device. Surgeons creating ileal pouches using staplers, or indeed any use of this particular stapler, need to be aware of this potential for a defect in the staple line and should take steps to avoid the defect or repair it depending on the circumstances.
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Affiliation(s)
- C M Byrne
- Department of Surgery, St Marks Hospital, Harrow, England, UK
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Das P, Smith JJ, Tekkis PP, Heriot AG, Antropoli M, John Nicholls R. Quality of life after indefinite diversion/pouch excision in ileal pouch failure patients. Colorectal Dis 2007; 9:718-24. [PMID: 17764535 DOI: 10.1111/j.1463-1318.2007.01216.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Pouch failure occurs in up to 10% of patients over a 10-year period for a variety of reasons. One surgical option is pouch excision (PE) and form a permanent ileostomy. This is a major procedure with potential serious complications. An alternative is indefinite diversion (ID) of the pouch without excision. The aim of this study was to examine the quality of life and functional outcome in these two groups of patients. METHOD Ninety-seven patients were identified from the database to have either PE or ID. Fifty-three patients (17 men) responded; comprising 31 patients after PE and 22 patients with ID in a case-control study and completed the SF-36 general health survey and the Cleveland Clinic Foundation (CCF) functional outcomes questionnaire. RESULTS There was no significant difference in the domains of SF-36 between the two groups (P > 0.18). All patients with PE had an end ileostomy whereas most patients with ID had a loop ileostomy (18 loop vs 4 end). There was no difference in stoma related complications except for stoma retraction in ID (7%vs 47%; P = 0.003). There was no significant difference in urinary symptoms between PE and ID groups (weak stream 26%vs 14%; P = 0.49, nocturia 22%vs 4%; P = 0.12, urgency 22%vs 9%; P = 0.28, urinary incontinence 22%vs 14%; P = 0.72 respectively). There was no difference in sexually active patients (73%vs 94%; P = 0.11). Of the seven male PE patients, five (71%) could achieve an erection and four (57%) could maintain an erection, compared with all 10 male patients in the ID group (P = 0.151 and 0.05 respectively). Thirty-three per cent of patients with PE and 62% of patients with ID reported that they would have pouch surgery again if indicated (P = 0.052) and 58% of patients with PE and 81% of patients with ID reported that they would recommend pouch surgery to others (P = 0.129). No case of dysplasia was seen in 18 of 22 ID patients in whom histology was available. CONCLUSION Quality of life after PE or ID was no different and male sexual function was significantly better after ID. Retraction of the stoma was more common in this group.
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Affiliation(s)
- P Das
- Department of Surgery, St Mark's Hospital, Harrow, Middlesex, UK
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Wasmuth HH, Svinsås M, Tranø G, Rydning A, Endreseth BH, Wibe A, Myrvold HE. Surgical load and long-term outcome for patients with Kock continent ileostomy. Colorectal Dis 2007; 9:713-7. [PMID: 17784871 DOI: 10.1111/j.1463-1318.2007.01264.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the results of Kock continent ileostomy (CI) during the same period when ileal pouch-anal anastomosis was the preferred operation for patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP). METHOD During the period 1983-2002, 50 patients underwent CI. The surgical technique was unchanged during the period. Follow-up included all patients. Forty-eight patients had UC, two of these had the diagnosis later changed to Crohn's disease and two had FAP. RESULTS Twenty-two patients had 38 reoperations, four (8%) of whom had the pouch removed. The main causes for reoperation included leakage and difficulty in intubation due to sliding of the nipple valve (42%), fistula formation (29%) and stenosis (21%). Seventeen (45%) underwent a revision of the nipple valve and the pouch and nine (24%) a local procedure. The reoperation rate was higher among patients having a conventional ileostomy converted to CI than among those having CI. As a primary procedure (P = 0.016). The risk of a second reoperation was higher for those reoperated within the first year after having a CI, than for those reoperated later (P = 0.007). CONCLUSIONS The reoperation rate of patients with CI is high but the removal rate of the pouch is low and is not associated with a high rate of revision. CI is a good alternative to conventional ileostomy in patients not suitable for restorative proctocolectomy or where this procedure has failed.
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Affiliation(s)
- H H Wasmuth
- Department of Surgery, St. Olavs Hospital HF, University Hospital of Trondheim, Trondheim, Norway.
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Miki C, Ohmori Y, Yoshiyama S, Toiyama Y, Araki T, Uchida K, Kusunoki M. Factors predicting postoperative infectious complications and early induction of inflammatory mediators in ulcerative colitis patients. World J Surg 2007; 31:522-9; discussion 530-1. [PMID: 17334865 DOI: 10.1007/s00268-006-0131-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Positive outcomes after restorative proctocolectomy are compromised by a number of specific septic complications. However, there is no useful perioperative marker predicting postoperative infectious complications (PICs) in steroid overdosed patients with ulcerative colitis (UC). METHODS To determine factors associated with PICs and their relation to circulating levels of pro- and anti-inflammatory cytokines and neutrophil elastase (NE), we obtained perioperative blood samples from 60 UC patients. RESULTS Postoperative infectious complications were identified in 47% of cases. Patients who developed PICs had significantly longer disease duration, had been administered a greater total preoperative dosage of prednisolone, and had a higher body mass index. Logistic regression analysis showed that the total preoperative dosage of prednisolone was independently associated with the development of PICs. These patients showed suppressed systemic inflammation and pro- and anti-inflammatory cytokine induction. An early increase in the NE level was found to be predictive of PICs in the high-dose group, whereas there was no significant difference in neutrophil counts between the high- and low-dose groups. CONCLUSIONS Circulating NE levels in the early postoperative period might be a useful predictor of PICs in immune-controlled UC patients who received high doses of steroids.
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Affiliation(s)
- Chikao Miki
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, 514-8507, Tsu, Mie, Japan
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43
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Lovegrove RE, Heriot AG, Constantinides V, Tilney HS, Darzi AW, Fazio VW, Nicholls RJ, Tekkis PP. Meta-analysis of short-term and long-term outcomes of J, W and S ileal reservoirs for restorative proctocolectomy. Colorectal Dis 2007; 9:310-20. [PMID: 17432982 DOI: 10.1111/j.1463-1318.2006.01093.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The choice of ileal pouch reservoir has been a contentious subject with no consensus as to which technique provides better function. This study aimed to compare short- and long-term outcomes of three ileal reservoir designs. METHOD Comparative studies published between 1985 and 2000 of J, W and S ileal pouch reservoirs were included. Meta-analytical techniques were employed to compare postoperative complications, pouch failure, and functional and physiological outcomes. Quality of life following surgery was also assessed. RESULTS Eighteen studies, comprising 1519 patients (689 J pouch, 306 W pouch and 524 S pouch) were included. There was no significant difference in the incidence of early postoperative complications between the three groups. The frequency of defecation over 24 h favoured the use of either a W or S pouch [J vs S: weighted mean difference (WMD) 1.48, P < 0.001; J vs W: WMD 0.97, P = 0.01]. The S pouch was associated with an increased need for pouch intubation (S vs J: OR 6.19, P = 0.04). The use of a J pouch was associated with a significantly higher prevalence of use of anti-diarrhoeal medication (J vs S: OR 2.80, P = 0.01; J vs W: OR 3.55, P < 0.001). CONCLUSION All three reservoirs had similar perioperative complication rates. The S pouch was associated with the need for anal intubation. There was less frequency and less need for antidiarrhoeal agents with the W rather than the J pouch.
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Affiliation(s)
- R E Lovegrove
- Imperial College London, Department of Biosurgery and Surgical Technology, St Mary's Hospital, London, UK
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Yantiss RK, Odze RD. Pitfalls in the interpretation of nonneoplastic mucosal biopsies in inflammatory bowel disease. Am J Gastroenterol 2007; 102:890-904. [PMID: 17324129 DOI: 10.1111/j.1572-0241.2007.01105.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This review provides a summary of common diagnostic problems encountered by both pathologists and gastroenterologists when evaluating patients with diarrhea and in whom inflammatory bowel disease (IBD) is suspected. The two most common forms of IBD, ulcerative colitis (UC) and Crohn's disease (CD), may, in certain settings, show overlapping endoscopic and pathologic features, potentially resulting in diagnostic confusion. For instance, some cases of UC may show unusual CD-like features, such as rectal sparing, discontinuous disease, aphthous ulceration, ileal or extracolonic involvement, and granulomatous inflammation, all of which may be evident in mucosal biopsy specimens. CD may also present as a diffuse, superficial pancolitis with ileal sparing that mimics the endoscopic and histologic appearance of UC. Furthermore, other forms of colitis, such as microscopic colitis, diverticulitis, diversion colitis, and nonsteroidal anti-inflammatory drug (NSAID)-induced colonic injury may also show IBD-like changes in mucosal biopsies. The potential diagnostic pitfalls faced by physicians, as well as features that aid in the distinction among these entities, are discussed in detail in this review.
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Affiliation(s)
- Rhonda K Yantiss
- Department of Pathology and Laboratory Medicine of the Weill Medical College of Cornell University, New York, New York, USA
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45
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Lovegrove RE, Tilney HS, Heriot AG, von Roon AC, Athanasiou T, Church J, Fazio VW, Tekkis PP. A comparison of adverse events and functional outcomes after restorative proctocolectomy for familial adenomatous polyposis and ulcerative colitis. Dis Colon Rectum 2006; 49:1293-306. [PMID: 16830218 DOI: 10.1007/s10350-006-0608-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Richard E Lovegrove
- Imperial College London, Department of Biosurgery and Surgical Technology, St. Mary's Hospital, Praed Street, London, United Kingdom
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46
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Lichtenstein GR, Cohen R, Yamashita B, Diamond RH. Quality of life after proctocolectomy with ileoanal anastomosis for patients with ulcerative colitis. J Clin Gastroenterol 2006; 40:669-77. [PMID: 16940876 DOI: 10.1097/00004836-200609000-00002] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Ulcerative colitis, a chronic inflammatory disease of the rectal and colonic mucosa, affects approximately 250,000 to 500,000 people in the United States, with 30% to 40% of patients requiring some form of surgical intervention during the course of their disease. The predominant reason for total proctocolectomy is for symptoms refractory to currently available medical therapy. Less common reasons are dysplasia or cancer. The goal of colectomy is to prevent recurrence of systemic inflammatory disease. Consequently, surgery with total proctocolectomy and creation of an ileal J-pouch-anal anastomosis has become the procedure of choice for many patients without other therapeutic options. Health-related quality of life (QOL) in patients with severe ulcerative colitis is so poor that, after ileal J-pouch-anal anastomosis, QOL is considered to improve in most clinical studies (8 studies, improved QOL; 1 study, no change; 1 study, QOL worse than general population). However, QOL and bowel function after such surgery cannot be considered "normal" in all patients, because a substantial number still have problems with urgency, leakage, nocturnal soiling, sexual dysfunction, and pouchitis, and some require conversion to a permanent ileostomy after ileal J-pouch-anal anastomosis failure. Thus, despite the availability of ileal J-pouch-anal anastomosis, surgery does not always restore all aspects of QOL to normal.
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Affiliation(s)
- Gary R Lichtenstein
- Center for Inflammatory Bowel Disease, University of Pennsylvania Health System, Philadelphia, PA, USA.
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Tekkis PP, Heriot AG, Smith JJ, Das P, Canero A, Nicholls RJ. Long-term results of abdominal salvage surgery following restorative proctocolectomy. Br J Surg 2006; 93:231-7. [PMID: 16432813 DOI: 10.1002/bjs.5242] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND This study evaluated outcomes of patients who underwent abdominal salvage ileal pouch redo surgery and identified factors associated with pouch failure following restorative proctocolectomy. METHODS Data on patients who underwent abdominal salvage surgery in a tertiary referral centre between 1985 and 2003 were collected. Outcomes studied included failure of salvage and bowel function of patients with an intact intestine. RESULTS One hundred and twelve patients underwent 117 pouch salvage procedures for ulcerative colitis (86), indeterminate colitis/ulcerative colitis (eight), indeterminate colitis/Crohn's disease (three), familial adenomatous polyposis (ten) and other conditions (five). The most common indications for pouch salvage were intra-abdominal sepsis (45 patients), anastomotic stricture (13) and retained rectal stump (35). Median follow-up was 46 (range 1-147) months. Twenty-four patients (21.4 per cent) experienced pouch failure, the incidence of which increased with time. The pouch failed in all patients with Crohn's disease. Successful salvage at 5 years was significantly associated with non-septic (85 per cent) rather than septic (61 per cent) indications (P = 0.016). Frequency of night-time defaecation and faecal urgency improved after salvage surgery (P = 0.036 and P = 0.016 respectively at 5-year follow-up; n = 32). CONCLUSION Abdominal salvage surgery was associated with a failure rate of 21.4 per cent. A successful outcome was less likely when the procedure was carried out for septic compared with non-septic indications. The rate of pouch failure increased with length of follow-up.
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Affiliation(s)
- P P Tekkis
- Department of Surgery, St Mark's Hospital, Watford Road, Harrow HA1 3UJ, UK
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Abstract
This review summarizes some of the common diagnostic problems encountered by pathologists when evaluating patients with chronic colitis and in whom inflammatory bowel disease (IBD) is either suspected or within the differential diagnosis. Both ulcerative colitis (UC) and Crohn's disease (CD) show characteristic, but non-specific, pathological features that may overlap and result in a diagnosis of 'indeterminate colitis' (IC). However, other reasons why pathologists may entertain a diagnosis of IC include failure to recognize or accept certain 'hardcore' histological features as indicative of CD, an attempt to classify cases of chronic colitis based on mucosal biopsy material or in the absence of adequate clinical and radiographic information, and the presence of other disease processes that mask, or mimic, IBD. In addition, some cases of UC may show unusual CD-like features, such as discontinuous or patchy disease, ileal inflammation, extracolonic inflammation, granulomatous inflammation in response to ruptured crypts, aphthous ulcers, or transmural inflammation. Furthermore, other forms of colitis, such as microscopic colitis, diverticulitis and diversion colitis may, on occasion, also show IBD-like changes. The clinical and pathological features that aid in the distinction between these entities, and others, are covered in detail in this review.
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Affiliation(s)
- R K Yantiss
- Department of Pathology, Weill Medical College of Cornell University, New York, NY, USA
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49
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Abstract
Familial adenomatous polyposis (FAP) is an autosomal-dominant colorectal cancer syndrome, caused by a germline mutation in the adenomatous polyposis coli (APC) gene, on chromosome 5q21. It is characterized by hundreds of adenomatous colorectal polyps, with an almost inevitable progression to colorectal cancer at an average age of 35 to 40 yr. Associated features include upper gastrointestinal tract polyps, congenital hypertrophy of the retinal pigment epithelium, desmoid tumors, and other extracolonic malignancies. Gardner syndrome is more of a historical subdivision of FAP, characterized by osteomas, dental anomalies, epidermal cysts, and soft tissue tumors. Other specified variants include Turcot syndrome (associated with central nervous system malignancies) and hereditary desmoid disease. Several genotype-phenotype correlations have been observed. Attenuated FAP is a phenotypically distinct entity, presenting with fewer than 100 adenomas. Multiple colorectal adenomas can also be caused by mutations in the human MutY homologue (MYH) gene, in an autosomal recessive condition referred to as MYH associated polyposis (MAP). Endoscopic screening of FAP probands and relatives is advocated as early as the ages of 10-12 yr, with the objective of reducing the occurrence of colorectal cancer. Colectomy remains the optimal prophylactic treatment, while the choice of procedure (subtotal vs proctocolectomy) is still controversial. Along with identifying better chemopreventive agents, optimizing screening of extracolonic cancers and applying new radiological and endoscopic technology to the diagnosis and management of extracolonic features are the major challenges for the future.
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Affiliation(s)
- Polymnia Galiatsatos
- Division of Gastroenterology, Department of Medicine, The Sir Mortimer B. Davis Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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50
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Yantiss RK, Farraye FA, O'Brien MJ, Fruin AB, Stucchi AF, Becker JM, Reddy SI, Odze RD. Prognostic Significance of Superficial Fissuring Ulceration in Patients With Severe “Indeterminate” Colitis. Am J Surg Pathol 2006; 30:165-70. [PMID: 16434889 DOI: 10.1097/01.pas.0000189178.00440.bf] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Some colectomy specimens from patients with severe colitis contain superficial fissuring-type ulcers but do not have any other features of Crohn's disease (CD). This finding may cause difficulty with regard to distinguishing ulcerative colitis (UC) from CD and, thus, lead to a diagnosis of "indeterminate" colitis. The aim of this study was to evaluate the clinical and pathologic features, and outcome, of a cohort of patients with colitis and superficial fissuring ulcers, but without any other features that may suggest a diagnosis of CD. We retrospectively identified 21 patients (male-to-female ratio, 10/11; mean age, 38 years) with severe chronic active colitis, all of whom had at least one (range, 1-3) superficial fissuring ulcer in their colectomy specimens (but without any other features of CD), as well as a control group of 18 patients (male-to-female ratio, 10/8; mean age, 41 years) with equally severe disease, but without fissuring ulcers. Both groups were evaluated for a variety of clinical and pathologic features, such as clinical presentation, degree, extent, and duration of colitis, and follow-up information, such as the development of pouchitis, pouch fistulae, and any other features of CD. Overall, 81% of the study patients presented clinically with fulminant colitis and underwent an emergent or urgent colectomy, compared with only 41% of the control patients (P = 0.02). Nine (43%) study patients had active serositis in their colectomy specimens, whereas only 1 (6%) control patient had this finding (P = 0.002). However, no significant differences were noted in either the extent or severity of disease or the presence of active ("backwash") ileitis, between the study and control groups. Upon follow-up (mean, 42 months; range, 4-121 months), the study patients with superficial fissuring ulcers developed pouchitis significantly more often (68% vs. 20%, P = 0.007) than the control group following an ileal pouch-anal anastomosis (IPAA) procedure. One patient from each group developed an anal fissure and another from each group developed an anastomotic stricture. In addition, 1 study patient developed a pouch-cutaneous fistula, and 1 control patient developed an enterocutaneous fistula to a loop ileostomy. Finally, 1 control patient ultimately had her pouch excised because of recurrent intractable pouchitis. However, none of the other study or control patients developed any clinical or pathologic manifestations of CD. We conclude that superficial fissuring ulcers may occur in patients with severe chronic active UC, particularly those who present with fulminant disease. Affected individuals should not be considered to have CD or "indeterminate" colitis and should not be denied an IPAA procedure. Nevertheless, the presence of superficial fissuring-type ulcers in patients with severe chronic active UC denotes a subgroup with a higher risk of pouchitis following surgical resection.
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Affiliation(s)
- Rhonda K Yantiss
- Department of Pathology, University of Massachusetts Medical School/UMass Memorial Health Care, Worcester, MA, USA.
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