Ileoanal Pouch Anastomosis Research Articles

Intrapelvic placement of a breast implant to allow deferred ileoanal pouch anastomosis after emergency proctocolectomy

Restoration of intestinal continuity at a second stage after emergency total proctocolectomy may be difficult or hazardous due to the pelvic cavity being closed off. We present a way of keeping the pelvic cavity open and accessible following total proctocolectomy by insertion of a breast implant that hinders fibrosis and prevents intestinal loops from occupying the space. A 275ml silicone breast implant was placed in the pelvic cavity after total proctocolectomy and closure of the rectal stump. Three months after the initial surgery, the breast implant had kept the pelvic cavity open, facilitating identification of the rectal stump and creation of an ileoanal J-pouch at this second stage. The use of a breast implant to fill the pelvic cavity may facilitate restoration of intestinal continuity in second-stage surgery and thereby decrease the number of associated complications.

Surgery for inflammatory bowel disease in the era of laparoscopy

During the course of inflammatory bowel disease (IBD), surgery may be needed. Approximately 20% of patients with ulcerative colitis (UC) will require surgery, whereas up to 80% of Crohn's disease (CD) patients will undergo an operation during their lifetime. For UC patients requiring surgery, total proctocolectomy and ileoanal pouch anastomosis (IPAA) is the operation of choice as it provides a permanent cure and good quality of life. Nevertheless a permanent stoma is a good option in selected patients, especially the elderly. Minimally invasive surgery has replaced the conventional open approach in many specialized centres worldwide. Laparoscopic colectomy and restorative IPAA is rapidly becoming the standard of care in the treatment of UC requiring surgery, whilst laparoscopic ileo-cecal resection is already the new gold standard in the treatment of complicated CD of terminal ileum. Short term advantages of laparoscopic surgery includes faster recovery time and reduced requirement for analgesics. It is, however, in the long term that minimally invasive surgery has demonstrated its superiority over the open approach. A better cosmesis, a reduced number of incisional hernias and fewer adhesions are the long term advantages of laparoscopy in IBD surgery. A reduction in abdominal adhesions is of great benefit when a second operation is needed in CD and this influences positively the pregnancy rate in young women undergoing restorative IPAA. In developing the therapeutic plan for IBD patients it should be recognized that the surgical approach to the abdomen has changed and that surgical treatment of complicated IBD can be safely performed with a true minimally invasive approach with great patient satisfaction.

The emerging therapy with probiotics in the management of inflammatory bowel disease: current status

Inflammatory Bowel Disease (IBD) comprises Ulcerative Colitis (UC) and Crohn’s Disease (CD) with unknown aetiology. Most of the drugs used to treat IBD as standard treatment produce adverse effects during long term therapy. Evidence has suggested a role of intestinal microbiota in IBD. The use of probiotics and prebiotics is the natural approach to treat IBD. The objective of this article was to review the studies on probiotics that cover the therapeutic status in Inflammatory Bowel Disease. Appraisal of published articles from peer reviewed journals, search from PubMed and Wiley Blackwell website for English language publications using defined key words according to disease type. Studies have shown that probiotic agents play an important role in IBD and these are VSL#3, Bifido-ferminted milk, Escherichia coli Nissle 1917, Saccharomyces boulardi and “BIO-THREE for inducing remission in patients with active UC, for preventing relapses in inactive UC patients and also in UC patients with ileo-anal pouch anastomosis. Lactobacillllus rhamnosus GG and Lactobacillllus johnsonii LA1 can prevent endoscopic recurrences in patients with inactive CD. Probiotic intervention study designs in IBD patients searched were RCT vs Placebo / RCT vs standard treatment . Studies - with uncontrolled design, - with prebiotics intervention and with helminths were also searched. There is a promising role of probiotics and prebiotics in chronic mucosal inflammation that occurs in Inflammatory Bowel Disease. Sufficient evidence to support the role of probiotics in CD are not available. Well designed RCT studies based on intention -to- treat analyses are required.

Primary ileo-anal pouch anastomosis in patients with acute ulcerative colitis

IntroductionProctocolectomy with ileal pouch-anal anastomosis (IPAA) was performed in ulcerative colitis (UC) for emergent or urgent indications in three stages. Since the three-step procedure imposes enormous demands on a patient, there was an attempt to introduce primary IPAA for urgent indications. The aim of this study was to compare early complications after Hartmann's colectomy (HC) and IPAA in a selected group of patients.Material and methodsMedical records of 274 patients who underwent surgery for UC between 1996 and 2010 were retrospectively evaluated. Finally, a group of 77 patients with acute form of UC entered this study.ResultsAll patients were divided into two groups. Group 1 consisted of 32 (42%) patients who underwent HC, whereas group 2 comprised 45 (58%) patients after IPAA. There was no postoperative mortality. Respiratory failure occurred in 8 (24%) patients after HC and in 6 (14%) patients who underwent IPAA. Intra-abdominal sepsis developed in 4 (12%) patients after HC and in 8 (17%) undergoing IPAA. Fascia dehiscence was present in 3 (8%) patients after HC and in 4 (9%) with IPAA. Bowel obstruction occurred in 1 (4%) patient after the former operation and in 3 (6%) patients after the latter one. Wound infection was diagnosed in 6 (20%) patients after HC and in 9 (20%) after IPAA. The differences between the investigated groups of patients were not statistically significant.ConclusionsThe IPAA could be performed for urgent indications only in the patients with no critical dilatation of the colon or with active UC but without signs of severe malnutrition.

Rectosigmoid stump washout as an alternative to permanent mucous fistula in patients undergoing subtotal colectomy for ulcerative colitis in emergency settings

BackgroundRestorative proctocolectomy with ileopouch-anal anastomosis (IPAA) is the treatment of choice for intractable or complicated ulcerative colitis(UC). Elderly patients often present with acute colitis requiring emergent subtotal colectomy(SC). Frail patients are at risk of developing septic complications related to the closed rectosigmoidal stump, often requiring formation of a second stoma to be reversed at the time of completion proctectomy. This carries nuisance to such exhausted patients. We propose a simple and inexpensive trick to avoid the need for creating a mucous fistula.MethodsIPAA was performed as a 3-stage procedure in emergency settings. The rectosigmoidal stump was closed and placed subcutaneously; skin was closed over it. After SC, if patients showed signs of stump-related pelvic sepsis, a lavage of the rectal stump with povidone iodine solution and with saline was carried out as a rescue treatment aiming to avoid the need of opening the rectal stump to drain sepsis.ResultsThirty-five patients underwent SC for UC between 1987 and 2012. The skin was closed over the closed stump in the 20. Seven patients out of these 20 experienced early stump-related septic complication. In five cases, we were able to avoid opening of the rectal stump, and a second stoma was unnecessary. After opening the closed stump in the remaining ones, a prompt improving of symptoms was observed.ConclusionsRectal washout was well tolerated and avoided a second stoma in five out of seven patients, with better quality of life and body perception after IPAA surgery. This is relevant when dealing with geriatric patients, needing to completely recover before undergoing completion proctectomy.

Laparoscopic Restorative Proctocolectomy Without Diverting Loop Ileostomy in Patients With Familial Adenomatous Polyposis

: Background: Familial adenomatous polyposis (FAP) is a well-known entity for specialist\r\nand it has near 100% chance of malignant changes if does not managed surgically. In order\r\nto reduce the disadvantages of laparatomy and diverting ileostomy we present our\r\nresults of laparoscopic total proctocolectomy without diverting ileostomy.\r\nObjectives: The aim of this study was to present the results of laparoscopic total proctocolectomy\r\nand J pouch ileoanal anastomosis without diverting ileostomy in managing\r\npatients with familial adenomatous polyposis (FAP).\r\nPatients and Methods: Hospital records of 19 patients who were diagnosed with FAP and underwent\r\nlaparoscopic restorative proctocolectomy without ileostomy were retrospectively\r\nevaluated in this study. Early complications and demographic data were considered.\r\nResults: The mean age of patients was 34 years, with a standard deviation of 4.3 years. The\r\nmost common presenting symptom was rectal bleeding. Two weeks after the operation,\r\nno leakage was detected at the site of anastomosis, but some patients experienced temporary\r\ndiarrhea and fecal incontinence.\r\nConclusions: Laparoscopic total proctocolectomy and J Pouch ileoanal anastomosis without\r\ndiverting loop ileostomy seems to be a safe procedure in the management of FAP.

The ileo neo‐rectal anastomosis in patients with familial adenomatous polyposis: a prospective case series with long‐term follow up

In patients with familial adenomatous polyposis (FAP), removal of the colonic mucosa is essential to reduce the lifetime risk of developing cancer). For this purpose, ileo-pouch anal anastomosis (IPAA) has been the gold standard, but morbidity related to the dissection of the pelvis remains substantial. In an attempt to reduce the procedure-related complications of pelvic dissection, ileoneo-rectal anastomosis (INRA) has been developed. In this case series of FAP patients, the long-term functional results, morbidity and quality of life (QoL) of the INRA procedure were evaluated and compared with its early outcome. Long-term follow up of a consecutive group of eight FAP patients with an INRA procedure (between 1998 and 2005) was undertaken. Data on functional results, complications, manometry and endoscopy were recorded prospectively. Eight patients with FAP underwent the INRA procedure. The median number of defaecations over 24 h was five. No pelvic sepsis or bladder dysfunction occurred. One patient, in whom concomitant Crohn's disease was diagnosed in retrospect, was converted to IPAA. In the INRA patients, no sexual dysfunction occurred. Endoscopic examination showed normal mucosa without any evidence of polyp formation. Restorative surgery by means of the INRA procedure yields good functional results in FAP patients, without any pelvic dissection-related morbidity or regrowth of polyps in the neo-rectum.

Erratum to: Update of complications and functional outcome of the ileo-pouch anal anastomosis: overview of evidence and meta-analysis of 96 observational studies

Erratum to: Update of complications and functional outcome of the ileo-pouch anal anastomosis: overview of evidence and meta-analysis of 96 observational studies

Update of complications and functional outcome of the ileo-pouch anal anastomosis: overview of evidence and meta-analysis of 96 observational studies

ObjectiveThe objective of this study is to provide a comprehensive update of the outcome of the ileo-pouch anal anastomosis (IPAA).Data sourcesAn extensive search in PubMed, EMBASE, and The Cochrane Library was conducted.Study selection and data extractionAll studies published after 2000 reporting on complications or functional outcome after a primary open IPAA procedure for UC or FAP were selected. Study characteristics, functional outcome, and complications were extracted.Data synthesisA review with similar methodology conducted 10 years earlier was used to evaluate developments in outcome over time. Pooled estimates were compared using a random-effects logistic meta-analyzing technique. Analyses focusing on the effect of time of study conductance, centralization, and variation in surgical techniques were performed.ResultsFifty-three studies including 14,966 patients were included. Pooled rates of pouch failure and pelvic sepsis were 4.3% (95% CI, 3.5–6.3) and 7.5% (95% CI 6.1–9.1), respectively. Compared to studies published before 2000, a reduction of 2.5% was observed in the pouch failure rate (p = 0.0038). Analysis on the effect of the time of study conductance confirmed a decline in pouch failure. Functional outcome remained stable over time, with a 24-h defecation frequency of 5.9 (95% CI, 5.0–6.9). Technical surgery aspects did not have an important effect on outcome.ConclusionThis review provides up to date outcome estimates of the IPAA procedure that can be useful as reference values for practice and research. It is also shows a reduction in pouch failure over time.

Single-Incision Laparoscopic Total Colectomy

To present our experience with a single-incision laparoscopic total colectomy, along with a literature review of all published cases on single-incision laparoscopic total colectomy. A total of 22 cases were published between 2010 and 2011, with our patient being case 23. These procedures were performed in the United States and United Kingdom. Surgical procedures included total colectomy with end ileostomy, proctocolectomy with ileorectal anastomosis, and total proctocolectomy with ileopouch-anal anastomosis. Intraoperative and postoperative data are analyzed. Twenty-two of the 23 cases were performed for benign cases including Crohns, ulcerative colitis, and familial adenomatous polyposis. One case was performed for adenocarcinoma of the cecum. The mean age was 35.3 years (range, 13 to 64), the mean body mass index was 20.1 (range, 19 to 25), mean operative time was 175.9 minutes (range, 139 to 216), mean blood loss was 95.3mL (range, 59 to 200), mean incision length was 2.61cm (range, 2 to 3). Average follow-up was 4.6 months with 2 reported complications. Single-incision laparoscopic total colectomy is feasible and safe in the hands of an experienced surgeon. It has been performed for both benign and malignant cases. It is comparable to the conventional multi-port laparoscopic total colectomy.

Role of surgery in severe ulcerative colitis in the era of medical rescue therapy

Despite the growing use of medical salvage therapy, colectomy has remained a cornerstone in managing acute severe ulcerative colitis (ASC) both in children and in adults. Colectomy should be regarded as a life saving procedure in ASC, and must be seriously considered in any steroid-refractory patient. However, colectomy is not a cure for the disease but rather the substitution of a large problem with smaller problems, including fecal incontinence, pouchitis, irritable pouch syndrome, cuffitis, anastomotic ulcer and stenosis, missed or de-novo Crohn's disease and, in young females, reduced fecundity. This notion has led to the widespread practice of offering medical salvage therapy before colectomy in most patients without surgical abdomen or toxic megacolon. Medical salvage therapies which have proved effective in the clinical trial setting include cyclosporine, tacrolimus and infliximab, which seem equally effective in the short term. Validated predictive rules can identify a subset of patients who will eventually fail corticosteroid therapy after only 3-5 d of steroid therapy with an accuracy of 85%-95%. This accuracy is sufficiently high for initiating medical therapy, but usually not colectomy, early in the admission without delaying colectomy if required. This approach has reduced the colectomy rate in ASC from 30%-70% in the past to 10%-20% nowadays, and the mortality rate from over 70% in the 1930s to about 1%. In general, restorative proctocolectomy (ileoanal pouch or ileal pouch-anal anastomosis), especially the J-pouch, is preferred over straight pull-through (ileo-anal) or ileo-rectal anastomosis, which may still be considered in young females concerned about infertility. Colectomy in the acute severe colitis setting, is usually performed in three steps due to the severity of the inflammation, concurrent steroid treatment and the generally reduced clinical condition. The first surgical step involves colectomy and constructing an ileal stoma, the second - constructing the pouch and the third - closing the stoma. This review focuses on the role of surgical treatment in ulcerative colitis in the era of medical rescue therapy.

Early, minimally invasive closure of anastomotic leaks: a new concept

Chronic pelvic sepsis after ileoanal or coloanal anastomosis precludes ileostomy closure and, even if closure is ultimately possible, function of the neorectum is badly affected. Early closure of the anastomotic leak might prevent chronic pelvic sepsis and its adverse sequelae. In our experience of early closure in a consecutive group of six patients with a leaking low anastomosis (five with ileoanal pouch anastomosis and one after a low anterior resection), we were able to achieve anastomotic closure in five by means of initial endosponge therapy followed either by early suture (four patients) or endoscopic clip repair (one patient). Early minimally invasive closure of low anastomotic leaks is therefore possible provided that the para-anastomotic cavity is drained well prior to closure and the anastomosis is defunctioned.

Less adhesiolysis and hernia repair during completion proctocolectomy after laparoscopic emergency colectomy for ulcerative colitis

BackgroundThe aim of this study was to determine whether the need for adhesiolysis during completion proctectomy (CP) with ileopouch anal anastomosis (IPAA) is influenced by the surgical approach of the initial emergency colectomy for ulcerative colitis and the hospital setting.MethodsOne hundred consecutive patients who underwent CP with IPAA in our center between January 1999 and April 2010 were included. Emergency colectomy had been performed laparoscopically in 30 of 52 patients at the Academic Medical Center Amsterdam and in 6 of 48 patients at referring hospitals. Case files of these patients were retrospectively reviewed.ResultsSignificantly more extensive adhesiolysis was performed after open compared to laparoscopic colectomy (47 vs. 6%, P < 0.001). In univariate analysis, emergency colectomy at a referring hospital was also predictive for adhesiolysis (P = 0.003), but the open approach for the initial colectomy was the only independent predictive factor for the need for adhesiolysis (P < 0.001) in a multivariable ordinal logistic regression analysis. Operating time of CP was significantly longer when limited [18 (95% CI = 0–36) min] or extensive [55 (35–75) min] adhesiolysis had to be performed. The interval to CP was longer after open colectomy and after colectomy performed at a referring hospital. Significantly more incisional hernia corrections during CP were performed after open emergency colectomy (14 vs. 0%, P = 0.024). Overall morbidity and postoperative hospital stay of CP were not related to the surgical approach or the hospital setting of the emergency colectomy.ConclusionLaparoscopic as opposed to open emergency colectomy is associated with less adhesiolysis, fewer incisional hernias, and a shorter interval to completion proctectomy.

Genital and Subjective Sexual Response in Women After Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis—A Prospective Clinical Trial

Sexual dysfunction after ileo pouch anal anastomosis (IPAA) is common. The most systematic physical reaction to sexual stimulation is an increase in vaginal vasocongestion. Genital response can be assessed by vaginal pulse amplitude (VPA) using vaginal photoplethysmography. To assess whether restorative proctocolectomy with IPAA is associated with autonomic pelvic nerve damage and changes in subjective indices of sexual function in women. Female patients undergoing IPAA between April 2004 and January 2006 were included. During sexual stimulation (visual and vibrotactile) changes in vaginal vasocongestion were measured by vaginal photoplethysmography. Concurrently, quality of life (SF-36) and sexual functioning (FSFI, FSDS) were assessed using validated questionnaires. Primary endpoint was difference in VPA pre- and postoperatively. Secondary endpoints were differences in feelings of sexual arousal and estimated lubrication pre- and postoperatively and difference in psychological and sexual functioning pre-and postoperatively. Eleven patients were included. For eight patients (median age 37 [22-49 years]) pre- and postoperative data were collected. VPA analysis showed a significant reduction in vaginal vasocongestion during sexual stimulation postoperatively, P = 0.012. Subjective sexual arousal and estimated lubrication during the experiment, reported psychological and sexual functioning pre- and postoperative were not different. Vaginal vasocongestion after IPAA was significantly reduced in this small study; indicating that IPAA in women might possibly be associated with autonomic pelvic nerve damage or partial devascularization of the vagina. Subjectively reported sexual arousal, estimated lubrication, psychological and sexual functioning were not diminished. Future research should focus on the possible advantage of a full close rectal dissection in these patients.

Portal vein thrombus after pediatric proctocolectomy with ileoanal anastomosis

In adults, mesenteric venous thrombosis with extension into the portal system is a known complication of total proctocolectomy with pouch ileoanal anastomosis. Although frequently reported in adults, this complication is rare in pediatric patients undergoing this operation. We report 2 cases of adolescent patients with ulcerative colitis who experienced portal vein thrombosis after this procedure. Both were treated with systemic anticoagulation therapy with complete resolution of their clots. We recommend that mesenteric/portal venous thrombosis be considered in the differential diagnosis in any child presenting with fever, abdominal pain, and leukocytosis after restorative proctocolectomy with ileal pouch anastomosis and that imaging obtained to evaluate abdominal complaints in this population be directed toward ruling out this complication.

Restorative proctocolectomy with ileal pouch-anal anastomosis for refractory or fulminant ulcerative colitis: Functional outcomes

Background: Ulcerative colitis is a chronic inflammatory disease of the colon and rectum. During the course of their disease, about 30% of patients with ulcerative colitis (UC) will undergo proctocolectomy with ileal pouch-anal anastomosis (IPAA). Restorative proctocolectomy with IPAA is considered the procedure of choice for patients with UC requiring surgery. Patients and methods: A prospective series of 20 patients from January 2004 till June 2008, presented with refractory or fulminant ulcerative colitis underwent restorative proctocolectomy with construction of J-pouch ileoanal anastomosis at Ain Shams University Hospitals and Ain Shams Specialized Hospital. The patients were 14 females (70%) and 6 males (30%) with an average age of 35.52±8.21 years (range: 24-48) years. Two-stage procedure was done in good risk patients while in high risk patients the three-stage procedure was adopted. The average follow up time was 34.21±15.32 months (range: 12-60) months. All patients were studied one month after closure of ileostomy with evacuation pouchography to assess the function and efficiency of evacuation of the pouch. In our study, the primary aim was to assess the postoperative complications as well as the functional outcome following restorative proctocolectomy with J- pouch ileoanal anastomosis for ulcerative colitis. Results: The average postoperative hospital stay was 23.52±8.56 days (range: 10-32) days. Only 2 patients (10%) had the three-stage procedure, while 18 patients (90%) had the two-stage procedure. The average follow up time was 34.21±15.32 months (range: 12-60) months. No intra or postoperative mortalities. Nine patients (45%) had morbidities and all were managed conservatively. Six patients (30%) developed variable degrees of wound infection and one patient (5%) had minor anastomotic leak. Minor incontinence was recorded in 7 patients (35%) and it was significantly improved in 5 of them during the first 12-18 months after closure of ileostomy. Anastomotic stricture developed in two patients (10%), managed by repeated sessions of dilatation. Skin excoriation surrounding Ileostomy were found in four patients (20%).Two patients (10%) suffered from adhesive intestinal obstruction after closure of ileostomy. Recurrent pouchitis developed in six patients (30%) and was controlled by metronidazole. The efficiency of the pouch evacuation was highly dependent on each of the pouch anal angles during rest and during straining. The final functional outcome was satisfactory in all patients

Ileoanal pouch dysfunction and the use of a Medena catheter following hospital discharge

With the advent of new surgical techniques to manage colorectal disease, the number of ileoanal pouch operations has amplified and therefore increased numbers of pouch patients are being discharged into the community setting. Community nurses will now encounter the ileoanal pouch patient and may be required to manage related complications. Restorative proctocolectomy with ileoanal pouch anastomosis (RPC) has become established as the gold standard operation for patients with ulcerative colitis (UC) and selected patients with familial adenomatous polyposis (FAP). Using a reservoir constructed from small bowel as a substitute rectum is a medical triumph which in the majority of cases improves the quality of life for patients, not only by eradicating disease and preserving anal sphincter function but also by avoiding a permanent ileostomy. Recent investigation into the use of Medena catheterization for pouch dysfunction has found that it is tolerated in the long-term and is associated with satisfactory quality of life in pouch patients with outflow obstruction.

Role of Water-Soluble Enema before Takedown of Diverting Ileostomy for Low Pelvic Anastomosis

The integrity of a low pelvic anastomosis is often studied radiographically before takedown of a diverting ileostomy. The aim of this study is to determine the impact of routine water-soluble enema studies (WSE) in our patient population with low pelvic anastomosis. We retrospectively reviewed the operative database for a county teaching hospital from 1998 to 2008. All patients with low pelvic anastomosis (ultralow colorectal, coloanal, and ileoanal pouch anastomosis) with diverting ileostomy who underwent subsequent takedown were identified. Fifty patients met inclusion criteria. Thirty-eight patients were evaluated by WSE and 12 were not. Twenty-five patients (66%) were noted to have normal WSE studies before ostomy takedown. Thirteen patients (26%) were noted to have abnormalities on WSE. Two stenoses were clinically significant. Water-soluble enema study was 100 per cent sensitive and 69 per cent specific for detecting significant pathology. Digital rectal examination (DRE), colonoscopy, and flexible sigmoidoscopy were also 100 per cent sensitive in detecting substantial pathology. Routine use of WSE failed to demonstrate a significant impact on patients with low pelvic anastomosis undergoing ileostomy takedown. Routine DRE and rigid proctoscopy can be used to evaluate low pelvic anastomosis. WSE can be used selectively on patients with abnormal findings.

Outcomes in pediatric patients undergoing straight vs J pouch ileoanal anastomosis: a multicenter analysis

Background Outcomes remain controversial for patients undergoing straight (SIAA) vs J pouch (JPAA) ileoanal anastomosis, particularly in children where fewer such cases are performed. Our 3 centers have had extensive experience with both techniques. Thus, we had the unique opportunity to compare outcomes within the same centers. Methods We retrospectively analyzed 250 children after proctocolectomy with either SIAA or JPAA, for the first 3 years after pull-through. A functional stooling score was developed to further assess outcomes. Data were analyzed using χ 2 tests and generalized linear mixed models for repeated measures. Results Two hundred three patients had sufficient data for complete analysis (42% males; mean surgery age, 15 ± 7years). Surgical indications were ulcerative colitis (168) and familial adenomatoid polyposis (35). Surgical procedures included SIAA (112) and JPAA (91). Daytime and nighttime stooling frequencies were significantly higher ( P < .013) for SIAA patients at 1 to 24 months after pull-through; however, stooling frequencies began approximating each other by this time. Symptomatic pouchitis (compared to enteritis after SIAA) was significantly higher in JPAA patients (odds ratio, 4.5; confidence interval, 2.32-8.72). Frequency of pouchitis declined with time. There was no significant difference in the incidence of surgical complications between the 2 groups. Finally, continence rates were strikingly good in both groups compared to previously reported series. Conclusion Straight ileoanal anastomosis and JPAA are associated with considerable morbidity; SIAA has higher stool frequency and JPAA has increased pouchitis. Over time, we found that problems improved, and functional stooling scores became similar. JPAA had consistently lower stool frequency and better continence rates; however, these differences were small and may have minimal clinical significance. In addition, such differences need to be balanced against the high rate of pouchitis with JPAA. Continence was excellent regardless of the technique.

Ileostomy adenocarcinoma associated with familial adenomatous polyposis (FAP): new problem in old disease

Dear Editor: Familial adenomatosis polyposis (FAP) is an autosomal dominant disease caused by germline mutations in the adenomatosis polyposis coli (APC) gene, which is located in chromosome 5. FAP occurs in approximately one in 5,000 to one in 10,000 live births and accounts for less than 1% of the total colorectal cancers in the USA. This disease is manifested by numerous adenomatous polyps of the large bowel and to a lesser extent in the gastric fundus, duodenal, periampullary, and small bowel. These colonic polyps invariably progress to adenocarcinoma, the risk of which approaches 100% by the fourth decade of life. With advancements made in the surgical techniques, prophylactic restorative proctocolectomy with ileoanal pouch anastomosis (IPAA) is currently the procedure of choice in younger, continent patients. Prior to the introduction of the restorative proctocolectomy with ileoanal pouch, total proctocolectomy with end ileostomy was the procedure most routinely performed in patients with FAP to completely abolish the colorectal mucosa and hence reduce the risk of colorectal malignancies. However, as these patients live longer and with functioning ileostomies of greater than 15–20 years, late development of adenocarcinoma has been reported in the literature. We describe another patient with FAP, who underwent total proctocolectomy and end ileostomy decades earlier, presented with a parastomal hernia and adenocarcinoma arising within a tubulovillous adenoma. To our knowledge, 11 cases including ours have been reported in English language journals. A 60-year-old white male patient with history of FAP, Gardner’s syndrome, underwent total proctocolectomy with end ileostomy in 1984. The final pathology then did not reveal any malignancy. He presented to surgical services in the year 2008 with complaints of a parastomal hernia, chronic skin irritation, and difficulty with proper placement of the stoma appliance. Examination revealed a reducible parastomal hernia in the right lower abdomen and multiple polypoidal projections of the mucosal surface of the ileostomy. A biopsy of the polyp was carried out, and the pathology revealed dilated adenomatous glands with severe dysplasia and dissecting pool of mucin diagnostic of adenocarcinoma. A staging workup was carried with a CT scan of the chest, abdomen, and pelvis which did not reveal any metastatic disease. Serum carcinoembryonic antigen (CEA) marker was within the normal range. An upper endoscopy did not reveal any abnormality, and an ileoscopy up to 80 cm through the ileostomy stoma did not reveal any other small bowel lesions. The patient underwent exploratory laparotomy and en bloc resection of the ileostomy with the surrounding skin, subcutaneous tissue, and distal 10 cm of the intraabdominal portion of the terminal ileum with its mesentery; repair of the hernial defect with a bioabsorbable mesh; and creation of a new ileostomy in the left lower quadrant. Postoperatively, he recovered well and was discharged without any complications. Int J Colorectal Dis (2009) 24:1475–1476 DOI 10.1007/s00384-009-0739-6