Conventional Proctocolectomy Research Articles

Persistent vaginal discharge following proctocolectomy—if there is no fistula, what is it?

Dear Editor: Distressing vaginal discharge following conventional proctocolectomy has been reported in up to 50 % of patients. The primary evaluation of such patients includes assessing for the presence of an enterovaginal fistula. We report a case of a patient who presented with distressing vaginal discharge lasting for 2 years after a conventional proctocolectomy. The discharge was found to be a result of the pelvic floor muscle shift and compression of the vagina, with a formation of a fluid reservoir in the upper third of the vagina. A 39-year-old woman with ulcerative colitis (UC) underwent an urgent total colectomy, rectal preservation, and end ileostomy for toxic colitis. The postoperative period was uneventful. Histopathological examination confirmed the diagnosis. Due to persistent rectal mucous discharge and her reluctance to have a completion proctectomy with ileal pouch and anal anastomosis, a perineal proctectomy was performed. The operation and the postoperative period were uneventful. Following the second operation, the patient complained of new onset vaginal discharge. She described recurrent episodes of sudden drainage of copious amount of fluid from the vagina, which was often brown or bloody and had an unpleasant odor. The patient underwent a gynecologic assessment which included repeated vaginal examinations and cultures, without findings. The comprehensive evaluation included transvaginal ultrasonography, computed tomography (CT), gastrografin enema, and magnetic resonance imaging (MRI) for the assessment of an enterovaginal fistula. All of the studies failed to identify a fistula, but the ultrasound, CT, and MRI demonstrated an accumulation of fluid in the upper vagina. An examination under anesthesia was performed, which also failed to diagnose a fistula. Two years after the second procedure, the patient was referred to a vulvovaginal clinic. Detailed history revealed that since analresection, the patient also had dyspareunia and a “phantom” anal pressure sensation. Upon palpation of the levator ani muscle, a ventral migration was noted. Insertion of a speculum was disrupted by a circular narrowing of the upper vagina. Passing the narrowing resulted in the drainage of large amount of fluid. The vagina appeared normal without inflammation, and microscopic evaluation of the discharge was negative. Review of the MRI films confirmed a pelvic floor muscle shift and the compression of the vagina, with the formation of a reservoir offluidintheupper third of the vagina. The patient was referred to pelvic floor physiotherapy, and following pelvic floor muscle relaxation and voluntary emptying of her vaginal contents, she became symptom free.

Adenocarcinomas after Prophylactic Surgery for Familial Adenomatous Polyposis

The incidence of familial adenomatous polyposis (FAP) is one in 7,000 to 12,000 live births. Virtually, all surgically untreated patients with FAP inevitably develop colorectal-cancer in their lifetime because they carry the adenomatous polyposis coli gene. Thus prophylactic proctocolectomy is indicated. Surgical treatment of FAP is still controversial. There are however, four surgical options: ileorectal anastomosis, restorative proctocolectomy with ileal pouch-anal anastomosis, proctocolectomy with ileostomy, and proctocolectomy with continent-ileostomy. Conventional proctocolectomy options largely lie between colectomy with ileorectal anastomosis or ileal pouch-anal anastomosis. Detractors of ileal pouch-anal anastomosis prefer ileorectal anastomosis because of better functional results and quality of life. The functional outcome of total colectomy with ileorectal anastomosis is undoubtedly far superior to that of the ileoanal pouch; however, the risk for rectal cancer is increased by 30%. Even after mucosectomy, inadvertent small mucosal residual islands remain. These residual islands carry the potential for the development of subsequent malignancy. We reviewed the literature (1975-2012) on the incidence, nature, and possible etiology of subsequent ileal-pouch and anal transit zone adenocarcinoma after prophylactic surgery procedure for FAP. To date there are 24 studies reporting 92 pouch-related cancers; 15 case reports, 4 prospective and 5 retrospective studies. Twenty three of 92 cancers (25%) developed in the pouch mucosa and 69 (75%) in anal transit zone (ATZ). Current recommendation for pouch surveillance and treatment are presented. Data suggest lifetime surveillance of these patients.

Review article: ulcerative colitis--surgical indications and treatment.

The indication for surgery is a balance between the severity of the disease despite full medical treatment and the potential disadvantages of surgery. The decision requires cooperation between gastroenterologist and surgeon. Colectomy with ileostomy and preservation of the rectum in the emergency setting is the accepted procedure and can rapidly restore the patient to normal health allowing withdrawal of anti-inflammatory medication. After recovery all surgical possibilities are then open for the future. The elective indications for surgery include failure of medical treatment, retardation of growth in a child or adolescent and neoplastic transformation. The choice of operation includes conventional proctocolectomy, restorative proctocolectomy (RPC) and colectomy with ileo-rectal anastomosis. Each has relative advantages and disadvantages. RPC is the commonest procedure. It offers a satisfactory outcome in 70-90% of patients with a cumulative failure rate of 10-15% over a 10 year period. Causes of failure include sepsis (50%), dysfunction (30%) and pouchitis (10%). In selected cases salvage surgery to avoid failure can be successful with rates of around 70% for outlet obstruction and fistulation and 50% for pelvic sepsis.

Fertility and pregnancy in inflammatory bowel disease.

Inflammatory bowel disease (IBD) is a chronic disorder affecting young adults in the reproductive years. It is common for both female and male patients with IBD to ask questions about IBD’s effect on their relationships, sexual and reproductive function, in particular fertility, the outcome of pregnancy and its possible effects on the disease. An open discussion of the social situation and education targeted at these issues therefore forms an essential part of the management of any young person with IBD. The questions that are most commonly asked are summarised in Table ​Table1.1. In order to answer these questions we need evidence. There are few large prospective case controlled studies to provide the information which is required but the available data, some of it from small observational studies, will be summarised in this chapter. Table 1 Questions commonly asked by IBD patients SEXUAL HEALTH It is well established that general measures of quality of life are impaired in patients with IBD[1]. Sexual health is an important aspect of quality of life which is often overlooked in a routine gastroenterological consultation. Sexual problems in IBD often seem to be focused around three major factors: body image problems, difficulties with social relationships and impaired sexual function[2]. Crohn’s disease (CD), in particular has been shown to have an impact on self-image, social relationships and sexual function[1]. Body image concerns are frequently found in IBD patients relating either to the direct physical effects of their disease such as weight loss, growth retardation as a result of chronically active disease in childhood, fistulae or perianal disease. The effect of surgery especially when a stoma is involved is associated with low self-esteem and poor body image. The side effects of steroids and other medications may lead to weight gain, hirsutism, skin changes and other features which promote feelings of unattractiveness. There is some evidence that psycho-social effects of stoma surgery performed in childhood, before puberty may be less severe than if such surgery is performed during the teenage and early adult years[3]. Partners of IBD patients with stomas have been found to be more likely to be able to accept the stoma than the patient themselves[4]. Psychological fears of loss of control of bodily functions and the fear of rejection by new or established partners in an intimate relationship all contribute to difficulties in social and sexual relationships. Counselling and practical advice and support is frequently helpful, but the need for it is not always identified in general gastroenterological practice. Some studies have reported an increase in sexual difficulties including dyspareunia in women who have had surgery for IBD and there is some evidence that patients with IBD may delay or even defer pregnancy because of their disease[4,5]. Most of the reports of sexual dysfunction are in women with Crohn’s disease. There are no specific reports of sexual dysfunction in women with ulcerative colitis (UC) who have not had previous surgery. In men with IBD the risk of impotence after proctocolectomy is the main concern[4]. Advances in surgical technique have decreased although not eliminated post-operative sexual dysfunction, and this seems to apply to both conventional proctocolectomy and pouch surgery with a reported incidence of impotence of around 4%-8%[6]. It is important to remember that patients are often quite reluctant to discuss such delicate matters and tactful prompting and adequate time during the consultation is the key to their detection.

Surgery for ulcerative colitis in the era of the pouch: the St Mark's Hospital experience.

The choice of operation for ulcerative colitis among 422 patients having all their surgery at one hospital between 1976 (the year of the first restorative proctocolectomy) and 1990, was reviewed. The 15 year period was divided into three quinquennia (1976-80, 1981-85, 1986-90). Elective surgery was performed in 316 patients with one operative death. The proportions of conventional proctocolectomy, colectomy with ileorectal anastomosis, and restorative proctocolectomy for the three quinquennia were 36/60, 17/60, 4/60; 29/111, 30/111, 35/111; 30/145, 17/145, 75/145. Of 106 urgent operations with three postoperative deaths, 12 had a conventional proctocolectomy and 86 a colectomy with ileostomy and preservation of the rectum. Of 85 survivors of the latter there were two late deaths and in 13 no further surgery had been done at the time of this assessment. In the remaining 70 having subsequent surgery the proportion of conventional proctocolectomy, colectomy with ileorectal anastomosis, and restorative proctocolectomy for the three quinquennia respectively were 19/27, 4/27, 14/27; 11/21, 2/21, 8/21; 5/22, 4/22, 13/22. Of the 76 patients having colectomy with ileorectal anastomosis 12 (16%) no longer had a functioning rectum at the end of 1990. Of the 153 patients having an ileoanal pouch procedure, 11 (7%) no longer had, a functioning anus. The study showed an increase in the numbers of patients having elective surgery for ulcerative colitis during the three quinquennia. It also showed a rise of restorative over conventional proctocolectomy with diminution in elective colectomy with ileorectal anastomosis in the last five year period.

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

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

Conservative protocolectomy with low transection of the anorectum is a poor alternative to conventional proctocolectomy in inflammatory bowel disease

The perineal wound is a frequent source of morbidity following proctocolectomy for inflammatory bowel disease. In 8 patients low transection of the anorectum or conservative proctocolectomy has been performed as an alternative to proctocolectomy in order to avoid a perineal wound. All patients passed copious mucoid discharge per anum post-operatively. Five patients required a proctectomy, 2 remain symptomatic and 1 patient has undergone a restorative proctocolectomy. This small series suggests conservative proctocolectomy does not seem to offer any advantage over conventional proctocolectomy in the surgical management of inflammatory bowel disease.

Gynaecological problems related to anatomical changes after conventional proctocolectomy and ileostomy

Seventy-one women who had a proctocolectomy for ulcerative colitis (n = 41) or Crohn's disease (n = 30) were interviewed in the follow-up clinic about gynaecological problems and fertility. All women were examined by an independent gynaecologist and abnormalities of the internal genital tract were registered. Forty-nine per cent (35/71) of the women had a distressing vaginal discharge after proctocolectomy, compared with 9% (6/71) before surgery. At the gynaecological examination 45% (32/71) had a heavy vaginal secretion with- out any signs of an acute vaginal infection. In 68% (30/44) fluid retention in the vagina was associated with a caudally firmly fixed and dilated posterior vaginal fornix. Twelve per cent (8/66) of the women reported dyspareunia before surgery. After surgery, 27% (18/66) complained of this symptom. Fertility was significantly reduced after surgery since only 37% (10/27) of the women who attempted to become pregnant succeeded within 5 years follow-up. The corresponding figure before surgery was 72% (39/54). Those who conceived went through pregnancy and parturition without any incident, 6 of 21 delivered by caesarean incision. In conclusion, conventional proctocolectomy in women will result in distressing vaginal discharge, and dyspareunia in a considerable proportion of the patients. The operation also seems to decrease their chances of becoming pregnant.

Surgery of the Anus, Rectum and Colon

Surgery of the Anus, Rectum and Colon