Ileal Pouch-anal Anastomosis Surgery Research Articles

Pathological subgroups may predict complications but not late failure after ileal pouch-anal anastomosis for indeterminate colitis.

Ileal pouch-anal anastomosis (IPAA) for indeterminate colitis (IndC) may lead to an increased risk of perineal complications and pouch loss. This study evaluated pathological subgroups of IndC to identify a predictor of increased complication rates after IPAA for IndC. Of 171 IPAAs with a postoperative diagnosis of IndC, IndC was confirmed in 115 of the 140 specimens available for re-examination. These were divided into IndC favouring ulcerative colitis (Group I; n = 99), 'true' IndC (Group II; n = 8), and IndC favouring Crohn's (Group III; n = 8). 61 presented with fulminant colitis. Patients in Group I were subdivided into having (A) deep ulcers (B) transmural lymphoid aggregates (C) skip lesions (D) terminal ileal inflammation and/or (E) a caecal patch. Outcome was determined by chart analysis, and compared to 231 randomly selected patients with IPAA for ulcerative colitis (UC) matched for age, gender, and follow-up. Only patients with evidence of deep ulceration (Group IA) had a significant increase in the incidence of Crohn's disease (4.3%vs. 0.43%, P = 0.04), complex perianal fistulae (4.3%vs. 0.43%, P = 0.04), and pelvic abscess (12.9%vs. 2.2%, P < 0.001). No pathological subgroup of IndC patients had a significantly different rate of pouch failure or pouch loss. Pathological stratification may predict those more likely to develop Crohn's disease or other complications, but not pouch failure. On this basis, we feel that patients with IndC should not be precluded from having IPAA surgery.

Pictorial essay. Radiology of ileal pouch-anal anastomosis surgery.

Pictorial essay. Radiology of ileal pouch-anal anastomosis surgery.

CT depiction of portal vein thrombi after creation of ileal pouch-anal anastomosis.

To determine the presence and location of portal vein thrombi in patients who have undergone ileal pouch-anal anastomosis (IPAA) and who were scanned with computed tomography (CT). During a 4-year period, 92 of 702 patients underwent contrast medium-enhanced CT after a total proctocolectomy with an IPAA. These CT scans were retrospectively reviewed for portal vein thrombus presence, location, and occlusive nature, as well as any accompanying enhancement abnormalities of the hepatic parenchyma. Only 13 patients who had initial CT scans that were positive for thrombi underwent follow-up examinations, and these were reviewed for resolution or progression of the original findings. Portal vein thrombi were present in 41 (45%) of the 92 patients; 24 (59%) of the 41 were isolated, often multiple, segmental right lobe thrombi. Five patients had both right and left segmental vein involvement. Eleven patients had various combinations of main portal vein, right and left portal vein, or segmental vein thrombi. One patient had an isolated superior mesenteric vein thrombus. Twenty-two of 25 superior mesenteric vein, main portal vein, and right and left portal vein thrombi were nonocclusive, while most (63 of 86) of the segmental vein thrombi were occlusive. Wedge-shaped, peripheral areas of hepatic parenchymal hyperenhancement that were distal to the thrombi were present in 30 (73%) of the 41 patients. Follow-up scans obtained in the 13 patients with portal vein thrombi showed thrombi resolved in five patients, progression to cavernous transformation occurred in one patient, and parenchymal enhancement changes persisted in seven patients. In the seven patients with persistent enhancement changes, four had complete resolution of thrombi. Portal vein thrombi appear to be relatively common after IPAA surgery and are most likely segmental, multiple, and occlusive. Peripheral wedge-shaped areas of hepatic parenchymal hyperenhancement commonly accompany these thrombi.

Surgical management of ulcerative colitis in the presence of primary sclerosing cholangitis.

The surgical management of ulcerative colitis in the patient with primary sclerosing cholangitis is controversial. This study was designed as a retrospective chart review of all patients with primary sclerosing cholangitis who were surgically treated for ulcerative colitis. Sixteen patients with primary sclerosing cholangitis and ulcerative colitis were identified. The indication for ulcerative colitis surgery was dysplasia in 7 patients (44 percent), cancer in 2 (13 percent), intractability in 4 (25 percent), and unknown in 1. Final colon pathology demonstrated cancer in three patients and dysplasia in four. Two patients had biliary cancer discovered at the time of orthotopic liver transplantation. Thirteen patients were known to have primary sclerosing cholangitis when they underwent surgery for ulcerative colitis; two patients with severe primary sclerosing cholangitis underwent simultaneous orthotopic liver transplantation/total abdominal colectomy and did well with subsequent ileal pouch reconstruction. Two patients had orthotopic liver transplantation first and then ileal pouch-anal anastomosis (1 patient) or total abdominal colectomy (1 patient) and did well. Seven patients had well-controlled primary sclerosing cholangitis on medication and underwent ileal pouch-anal anastomosis or total abdominal proctocolectomy without significant hepatic compromise. One patient with moderate primary sclerosing cholangitis underwent ileorectal anastomosis and had severe liver failure postoperatively but survived. Another patient with worsening primary sclerosing cholangitis after total abdominal colectomy has since developed persistent bleeding from peristomal varices. The overall cancer/premalignant lesion rate was high (50 percent in this study) in patients with primary sclerosing cholangitis and ulcerative colitis. Complications associated with the surgical management of ulcerative colitis are largely dictated by the degree of liver disease present at the time of surgery. Patients with significant primary sclerosing cholangitis that requires colectomy can undergo simultaneous orthotopic liver transplantation/total abdominal colectomy and then be candidates for subsequent ileal pouch-anal anastomosis reconstruction once liver function has improved. Patients with well-controlled primary sclerosing cholangitis can undergo ileal pouch-anal anastomosis surgery safely.

Quality of life of patients with mucosal ulcerative colitis following ileal pouch anal anastomosis surgery

Quality of life of patients with mucosal ulcerative colitis following ileal pouch anal anastomosis surgery

Functional outcomes in patients with mucosal ulcerative colitis after ileal pouch-anal anastomosis by the double stapling technique: is there a relation to tissue type?

The aim of this study was to evaluate any differences in functional outcome in patients with mucosal ulcerative colitis after restorative proctocolectomy and ileal pouch-anal anastomosis with use of the double stapling technique relative to the type of tissue in the stapled doughnut. Between September 1988 and June 1997, the pathology of all patients with mucosal ulcerative colitis who underwent ileal pouch-anal anastomosis with use of the double stapling technique were reviewed. Information was obtained regarding the tissue types in the distal tissue rings (doughnuts) obtained from the stapled ileal pouchanal anastomosis. The level of anastomosis was classified according to the type of tissue in the distal doughnut: Group I- patients in whom the anal transitional zone was removed and the distal doughnut included squamous epithelium or transitional epithelium and Group II- patients in whom the anal transitional zone was preserved because the distal doughnut revealed only columnar epithelium. Functional outcomes were assessed and compared by detailed questionnaires mailed to all patients at least one year after ileal pouch-anal anastomosis surgery. Distal doughnuts were obtained from the stapled ileal pouch-anal anastomosis in 222 patients with mucosal ulcerative colitis. Follow-up data at a mean of 38 (range, 12-132) months were obtained in 138 (62.2 percent) patients, including 72 males, with a mean age of 46.9 (range, 13-79) years. Group I consisted of 40 patients (29 percent; 35 (25.4 percent) who had squamous epithelium and 5 (3.6 percent) who had transitional epithelium in the distal tissue rings). Group II consisted of 98 patients (71 percent) with columnar epithelium in the distal tissue rings. Age at diagnosis and operation, duration of disease, length of follow-up, and stage of pouch surgery were similar in the two groups. Incontinence scores, frequency of bowel movement, use of a protective pad, discrimination between gas and stool, use of antidiarrheals, life-style alteration, and patient satisfaction showed similar functional results between the two groups. The tissue type in the stapler distal doughnut did not greatly influence functional outcome. Failure to identify a relationship may attest to the variable height and composition of the anal transitional zone.

Crohn's-like complications in patients with ulcerative colitis after total proctocolectomy and ileal pouch-anal anastomosis.

Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become an established surgical procedure for ulcerative colitis. Occasional patients who have undergone IPAA develop persistent or recurrent episodes of pouchitis (chronic pouchitis), from which a subset also develop gastrointestinal and systemic complications that are identical to those seen in Crohn's disease. These complications include enteric stenoses or fistulas in the pouch or pouch inlet segment, perianal fistulas or abscesses, pouch fistulas, arthritis, iridocyclitis, and pyoderma gangrenosum. The development of Crohn's-like gastrointestinal complications in a patient with chronic pouchitis frequently engenders concern that the pathologist misinterpreted the proctocolectomy specimen as ulcerative colitis instead of Crohn's disease. We describe eight patients who developed chronic pouchitis and Crohn's-like complications after IPAA and total proctocolectomy. In each case, concern was voiced about misinterpretation of the proctocolectomy specimen as ulcerative colitis instead of Crohn's disease after the development of the Crohn's-like complications. Preoperatively, all eight patients had characteristic clinical, radiographic, and pathologic features of ulcerative colitis. Review of the pathology specimens indicated that all eight had ulcerative colitis. Crohn's-like complications are most likely related to chronic pouchitis, which probably is a form of recrudescent ulcerative colitis within the novel environment of the pouch. A diagnosis of Crohn's disease after IPAA surgery should only be made when reexamination of the original proctocolectomy specimen shows typical pathologic features of Crohn's disease, Crohn's disease arises in parts of the gastrointestinal tract distant from the pouch, pouch biopsies contain active enteritis with granulomas, or excised pouches show the characteristic features of Crohn's disease, including granulomas. There were no histologic differences in the total colectomy specimens between the eight ulcerative colitis study patients and 16 control ulcerative colitis patients who had a favorable clinical outcome after IPAA surgery groups. Crohn's-like complications and chronic pouchitis does not necessarily imply an incorrect original interpretation of ulcerative colitis by the pathologist.