Ileostomy For Ulcerative Colitis Research Articles

P214 Effects of rectal stump proctitis on short-term postoperative complications after proctectomy and ileal pouch-anal anastomosis for Ulcerative Colitis

Abstract Background Inflammation of the rectal stump (proctitis) after subtotal colectomy with ileostomy for ulcerative colitis (UC) is common. Proctitis may affect the postoperative outcomes of ileal pouch-anal anastomosis (IPAA). This study aims to explore associations between rectal stump proctitis and short-term postoperative complications (POCs) after proctectomy and IPAA for UC. Methods This retrospective single-centre study included patients who underwent proctectomy, IPAA and protective ileostomy for UC from 2000-2023. Data were retrieved from our prospectively-maintained database. Exclusion criteria were dysplasia or cancer (103 pts), missing pathology results (50 pts), undetermined colitis or Crohn’s Disease features at proctectomy (18 pts). All patients underwent three-staged IPAA and were divided into four groups according to the rectal stump proctitis status at pathology: remission, mild, moderate, and severe proctitis. A stepwise binary logistic regression analysis was performed for each short-term outcome. Models included variables with a different distribution according to the outcome (p-value ≤0.1). Results We included 785 patients who underwent proctectomy and IPAA. At pathology, remission was achieved by 162 (20.6%) patients, while proctitis of the rectal stump was mild in 211 (26.9%), moderate in 246 (31.3%), and severe in 166 (21.1%) patients, respectively. Table 1 details population characteristics and outcomes according to the proctitis status. Patients with moderate and severe proctitis received more preoperative biologics and ongoing systemic steroids at surgery. While they underwent previous abdominal surgery less frequently, the laparoscopy rate was lower with a longer postoperative length of stay. At multivariate (Table 2), Medical POCs were independently associated with ongoing antibiotics (OR 2.29 [1.01-5.20] p=0.047) and ASA score≥3 (OR 1.93 [1.11-3.35] p=0.019). Surgical POCs were independently associated with ongoing systemic steroids (OR 2.09 [1.19-3.68] p=0.011, while ongoing antibiotics (OR 0.2 [0.04-0.86] p=0.031) and laparoscopy (OR 0.53 [0.28-1.00] p=0.049) were protective. Intra-abdominal septic complications (IASCs) and abdominal/pelvic abscesses were independently associated with the proctitis status (OR 1.1 [1.06-2] p=0.018 and OR 1.56 [1.08-2.25] p=0.017, respectively). Conclusion Rectal stump proctitis was independently associated with postoperative abdominal and pelvic abscesses and IASCs after proctectomy and IPAA for UC. The association between proctitis and IPAA’s long-term outcomes and pouch failure need to be further explored.

P655 The ileorectal anastomosis after a total colectomy is a feasible and valid surgical alternative in the treatment of inflammatory bowel disease

Abstract Background Colectomy is still necessary in some patients with inflammatory bowel disease (IBD). The decision of the technique for the restoration of the bowel continuity depends on the characteristics of the patient and whether it is Crohn’s disease (CD) or ulcerative colitis (UC). The options for the reconstruction are proctectomy with an ileoanal reservoir or an ileorectal anastomosis (IRa). The aim of this study is to evaluate the need of a proctectomy with a definitive ileostomy after an ileorectal anastomosis, the associated risk factors and the need for advanced therapies. Methods This retrospective study includes patients with colectomy and IRa from the ENEIDA national registry. Medical treatment offered during the postoperative follow up and the need for a proctectomy and a definitive ileostomy were evaluated according to the type of IBD. Results Of the 394 patients who underwent an IR, 37% had UC and 63% CD with a medium age of 58 years (RIQ 48-68) and a median follow-up after the IR of 174 months (RIQ 70- 266). 17% of UC’s patients and 42% of CD’s patients had associated perianal disease (p<0.001). The cumulative probability for a definitive ileostomy in UC’s patients was 1%, 2%, and 6% at 5, 10 and 20 years respectively and 1%, 3%, and 11% at 5, 10 and 20 years respectively for the CD (p=0.035). Postoperative maintenance treatment with biologicals was left in 45% (44% UC and 47% CD; p=0.28). During follow-up, the probability of starting biological treatment was 8%, 17%, 35% at 2, 5 and 10 years in CD and 3%, 12%, 28% at 2, 5 and 10 years in UC (p=0.59). Conclusion The probability of requiring a definitive ileostomy/proctectomy after an IR is low, although is more frequent in patients with CD than with UC. Because of this low probability an IR is a valid alternative to the reservoir or even to the proctectomy with a definitive ileostomy in selected patients, keeping in mind one third of the patients would need advanced therapies.

Single-incision laparoscopic clockwise continuous total abdominal colectomy with end ileostomy in ulcerative colitis; surgical technique and results of a 7-year experience

Total abdominal colectomy with end ileostomy is the first stage of the three-stage surgical treatment of medically refractory ulcerative colitis. Laparoscopic surgery is a safe approach offering several benefits. Single-incision laparoscopic surgery is an alternative minimally invasive approach providing excellent cosmetic results. Literature on single-incision laparoscopic clockwise continuous total abdominal colectomy in the treatment of ulcerative colitis is limited. Aim of the study is to describe our surgical technique and report the outcomes. Medically refractory ulcerative colitis patients who underwent single-incision laparoscopic clockwise continuous total abdominal colectomy with end ileostomy by a single surgeon between January 2013 and December 2020 at our tertiary care center are included. Patient charts were reviewed retrospectively. 52 patients were included in the final analysis. 51.9% patients were male with the median age of 31.5years and body mass index of 22.2kg/m2. Median duration of operation was 100min with estimated blood loss of 50ml. There were no intraoperative complications, conversions to conventional laparoscopy or open surgery. Postoperative complications were reported in 13 (25%) patients with most common being ileus (17.3%). 3 patients had surgical site infections. 2 patients had postoperative bleeding requiring blood transfusion. 2 patients had reoperation within postoperative 30days. Median length of hospital stay was 2days. No mortalities were reported. Single-incision laparoscopic clockwise continuous approach is safe and effective in ulcerative colitis patients undergoing total abdominal colectomy with end ileostomy. Further prospective randomized studies are warranted.

The Impact of Rectal Stump Inflammation After Subtotal Colectomy on Pouch Outcomes in Ulcerative Colitis Patients.

Background and AimsProctitis after subtotal colectomy with ileostomy for ulcerative colitis [UC] is common, but its impact on short- and long-term outcome after pouch surgery is unknown. The aim of this study was to determine the incidence of proctitis after subtotal colectomy and its impact on postoperative morbidity and pouchitis.MethodsThe distal margin of the rectal stump of all consecutive patients undergoing completion proctectomy and pouch procedure for UC, between 1999 and 2017, was revised and scored for active inflammation according to the validated Geboes score, and for diversion proctitis. Pathological findings were correlated to complications after pouch surgery and pouchitis [including therapy-refractory] using multivariate analyses.ResultsOut of 204 included patients, 167 [82%] had active inflammation in the rectal stump and diversion colitis was found in 170 specimens [83%]. Overall postoperative complications and anastomotic leakage rates were not significantly different between patients with and without active inflammation in the rectal stump [34.7% vs 32.4%, p = 0.79, and 10.2% vs 5.4%, p = 0.54, respectively]. Active inflammation of the rectal stump was significantly associated with the development of pouchitis [54.3% vs 25.5%, plog = 0.02], as well as with therapy refractory pouchitis [14% vs 0%, plog = 0.05]. Following multivariate analysis, active inflammation was an independent predictor for the development of pouchitis. Diversion proctitis showed no association with these outcome parameters.ConclusionsActive inflammation in the rectal stump after subtotal colectomy occurs in 80% of UC patients and is a predictor for the development of pouchitis and therapy-refractory pouchitis.

PTH-076 Inflammatory Bowel Disease: The Consequences of Anti-TNF Therapy in The Elderly

Introduction Existing literature regarding the efficacy and safety of anti-tumour necrosis factor (TNF) therapy in the elderly with inflammatory bowel disease (IBD) is scare and conflicting. The aim of this study is to assess the consequences of anti-TNF therapy (infliximab and adalimumab) in elderly patients with IBD. Methods A retrospective single-centre analysis of all patients ≥50 years-old who were commenced on an anti-TNF agent for IBD between September 2013 - August 2015 was performed. Patients who received less than 2 doses were excluded. The type of anti-TNF used was recorded, and whether immunomodulators were commenced prior to anti-TNF therapy. Data on treatment efficacy, treatment failure and adverse events was collected. Results 19/44 patients were male and 25/44 were female. The majority of patients (81.8%, 36/44) had a diagnosis of Crohn’s Disease, compared with 18.2% (8/44) with Ulcerative Colitis (UC). Results were analysed within subgroups based on age. The majority of patients (24/44, 55%) were aged 50–59, with 15/44 (34%) aged 60–69 and 4/44 (9%) aged 70–79. Treatment efficacy was measured by readmission with an IBD-flare and a requirement for surgery after being treated with anti-TNF. The rate of readmission with a flare was low across all age groups; of those aged 50–59, 8.3% (2/24) were readmitted, compared with 20% (3/15) aged 60–69 and 25% (1/4) aged 70–79. The median days for readmission following anti-TNF was >100 days. The number of patients who required surgery also represented a small proportion: 1 patient in age 50–59 band required anal stricture dilatation, and 2 patients in age 60–69 band required a subtotal colectomy and end ileostomy for UC. Adverse events were assessed by significant reactions to treatment, infections requiring hospitalisation, a malignancy presenting after treatment, and mortality. The incidence of these adverse events was low, and did not follow any pattern related to the age of the patient at treatment (Figure 1 and 2), and none of the deaths observed were directly related to IBD. 40% (6/15) of patients aged 60–69 required admission to hospital due to infection; however no patients in the age bands of 50–59 or 70+ had this outcome. The infective aetiology was diverse. The median days of presentation after starting anti-TNF was >200 days. Conclusion Treatment efficacy, failure and the incidence of adverse events among older patients on anti-TNF therapy appears to be low and unrelated to increasing age. Our research suggests that anti-TNF therapy is an effective and safe treatment option for IBD patients aged over 50 who have failed previous immunomodulator therapy. Reference 1 Lobaton et al. Efficacy and safety of anti-TNF therapy in elderly patients with inflammatory bowel disease. Aliment Pharmacol Ther. 2015 Aug;42(4):441–51. doi:10.1111/apt.13294. Epub 2015 Jun 24. Disclosure of Interest None Declared

Fate of the Rectal Stump After Subtotal Colectomy for Ulcerative Colitis in the Era of Ileal Pouch–Anal Anastomosis

Total proctocolectomy with ileal pouch-anal anastomosis is considered the procedure of choice for patients requiring elective surgery for ulcerative colitis, but some patients undergoing subtotal colectomy with end ileostomy are satisfied with an ileostomy and do not choose to undergo later pelvic pouch surgery. The need and timing for completion proctectomy in this setting are uncertain. To assess the long-term fate of the retained rectum compared with the morbidity associated with completion proctectomy in patients who underwent subtotal colectomy for ulcerative colitis. Retrospective review of a prospective database in an academic medical center. Patients who underwent subtotal colectomy with ileostomy for ulcerative colitis from July 1, 1990, to December 31, 2010. Proctectomy, surgical complications, and symptoms from the retained rectum. One hundred eight patients underwent subtotal colectomy for ulcerative colitis during the study period: 73 for acute disease, 18 for advanced age and/or comorbidities, and 17 to avoid the risk of sexual dysfunction or infertility. Of these patients, 71 (65.7%) underwent subsequent ileal pouch-anal anastomosis, 2 died of other causes, and 3 were lost to follow-up. Of the remaining 32 patients, 20 chose rectal stump surveillance and 12 underwent elective proctectomy. Median follow-up was 13.8 years. No difference was noted in age, sex, surgical complications, pad use, or urinary dysfunction between the 2 groups. Only 8 of 20 patients in the surveillance group were compliant with follow-up endoscopy, and 13 were able to maintain their rectum; 2 required proctectomy at 11 and 16 years, respectively, for rectal cancer; neither has developed recurrent disease. One patient in each group reported erectile dysfunction. Management of the retained rectum after subtotal colectomy remains an important issue even in the era of ileal pouch-anal anastomosis. Considering the risk of rectal cancer, the low success rate of long-term rectal preservation, and the safety of surgery, a more aggressive approach to early completion proctectomy seems justified in this situation.

Incomplete ileal anal pouch emptying

Gastrointestinal NursingVol. 9, No. 7 Skills in PracticeIncomplete ileal anal pouch emptyingJulia WilliamsJulia WilliamsSearch for more papers by this authorJulia WilliamsPublished Online:16 Aug 2013https://doi.org/10.12968/gasn.2011.9.7.15AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Norton C et al. (2009) Oxford Handbook of Gastrointestinal Nursing. Oxford University Press, Oxford Google ScholarParks AG, Nicholls RJ (1978) Procolectomy without ileostomy for ulcerative colitis. BMJ 2(6130): 85–8 Crossref, Google ScholarWilliams J (2002) (ed) The Essentials of Pouch Care Nursing. Whurr Publications, London Google Scholar FiguresReferencesRelatedDetailsCited byNurse activity to prevent and support patients with a parastomal hernia17 December 2015 | Gastrointestinal Nursing, Vol. 13, No. 10Analysing the role of support wear, clothing and accessories in maintaining ostomates' quality of life21 September 2015 | Gastrointestinal Nursing, Vol. 13, No. 7Assessing support garments in the management of parastomal hernia16 May 2014 | Gastrointestinal Nursing, Vol. 12, No. 4 1 September 2011Volume 9Issue 7ISSN (print): 1479-5248ISSN (online): 2052-2835 Metrics History Published online 16 August 2013 Published in print 1 September 2011 Information© MA Healthcare LimitedPDF download

Embolization of Bleeding Stomal Varices by Direct Percutaneous Approach

Stomal varices can occur in patients with stoma in the presence of portal hypertension. Suture ligation, sclerotherapy, angiographic embolization, stoma revision, beta blockade, portosystemic shunt, and liver transplantation have been described as therapeutic options for bleeding stomal varices. We report the case of a 21-year-old patient with primary sclerosing cholangitis and colectomy with ileostomy for ulcerative colitis, where stomal variceal bleeding was successfully treated by direct percutaneous embolization. We consider percutaneous embolization to be an effective way of treating acute stomal bleeding in decompensated patients while awaiting decisions regarding shunt procedures or liver transplantation.

Primary Adenocarcinoma of Ileostomy: Case Report with Review of the Literature

Primary adenocarcinoma is a rare and late complication following proctocolectomy and ileostomy for ulcerative colitis, familial adenomatous polyposis, Crohn's disease and multifocal colorectal cancer. We report a case of adenocarcinoma of the ileostomy occurring 48 years after proctocolectomy for ulcerative colitis. A review of the literature suggests that there are 39 cases reported in literature and this case reports the longest interval between formation of ileostomy and diagnosis of ileostomy adenocarcinoma. This case also reports lymph node metastasis to the adjacent mesenteric lymph node. The incidence of lymphnode metastasis is 15 percent as per literature. Onces diagnosis is confirmed by biopsy enblock excision with or without stomal relocation is the main stay of treatment. Patient education and regular surveillance of patients with long-standing ileostomy is recommended for early detection of this unusual cancer.

The effect of resection of the distal ileum on gastric emptying, small bowel transit and absorption after proctocolectomy.

Patients who had undergone proctocolectomy and ileostomy for ulcerative colitis have been studied. One group (contrast group) had undergone resection of only small amounts of terminal ileum (median = 4 cm), the other group of patients (study group) had undergone resection of greater lengths of small bowel (median = 60 cm). Gastric emptying and transit of a standard meal through the small bowel were estimated, whilst the amounts of fat, nitrogen, glucose, sodium and potassium excreted by the ileostomy were simultaneously determined. Significantly greater amounts of fat, nitrogen, sodium, potassium and water were excreted by patients who had undergone resection compared with contrast patients (P less than 0.01). The rate of gastric emptying was not increased in patients who had undergone ileal resection compared with contrast patients but small bowel transit within 4 hours of ingestion of the meal was significantly faster. A significant correlation between transit times and excretion of fat was also noted in patients (P less than 0.02). Thus, quite modest ileal resection in addition to proctocolectomy leads to rapid small bowel transit and marked malabsorption of nutrients as well as water and electrolytes.

Comparison of restorative proctocolectomy with and without covering ileostomy in ulcerative colitis

The experience of restorative proctocolectomy for ulcerative colitis is reported in 16 consecutive patients with no covering ileostomy (group 2) in comparison with 15 patients with a covering stoma (group 1); in each group a J pouch was constructed. All patients had pre- and postoperative clinical and manometric evaluations of the functional result up to 12 months. There were no deaths or permanent failures. The number of early complications was four in each group. Re-ileostomy was needed in one patient of group 1, and an ileostomy was constructed in three patients of group 2. At 1 year after operation the functional results did not differ between groups 1 and 2 in terms of daily frequency of defaecation (mean 5.6 and 5.4 in 24 h respectively), or in terms of anal basal or maximal squeeze pressures. There was a significant (P less than 0.01) saving in total hospital stay (median 11 days) and in operating theatre time (mean 41 min) in patients with no covering ileostomy. It is concluded that a covering ileostomy may be unnecessary in restorative proctocolectomy, at least in suitable cases with no technical difficulty at the time of operation.

Ostomy patients’ perceptions of quality of care

This paper reports a study whose aim was to assess the quality of care in ostomy patients seen from a patient perspective. A stoma operation causes profound changes in a patient's life because of resulting physical damage, disfigurement, loss of bodily function, and change in personal hygiene. Such changes are a cause of major concern for patients and raise important issue for the quality of care. The study group comprised patients who had undergone a colostomy for rectal cancer or an ileostomy for ulcerative colitis, all attending a stoma outpatient clinic. Quality of care was assessed using the identity-oriented dimension of the validated questionnaire 'Quality of Care from the Patient's Perspective'. Forty-two ileostomy and 49 colostomy patients completed the questionnaire. While the vast majority of patients in both groups thought that most topics in the questionnaire were important, most rated many aspects of their quality of care as unsatisfactory. One-third of the colostomy patients and one-half of the ileostomy patients were dissatisfied with the information they received about the results of medical examinations and laboratory tests, and an even higher proportion was dissatisfied with their opportunities to participate in the decision-making process or to discuss sexual matters. Stoma-related complications, which occurred in 71% of the ileostomy patients and in 43% of the colostomy patients, had no impact on these results. Information and counselling for patients having ostomies, both on the part of specialist nurses and colorectal surgeons, appeared to deficient, suggesting that standards for quality of care require continuous evaluation and revision.

Urgent Subtotal Colectomy for Severe Inflammatory Bowel Disease

The purpose of this study was to assess the safety of subtotal colectomy and outcomes after this procedure in the modern era of immunosuppressive agents and primary pelvic pouch surgery. All patients undergoing subtotal colectomy with ileostomy for ulcerative colitis or Crohn's colitis from July 1, 1990 to June 30, 2003 were identified from a prospective database. Only patients who were operated on while hospitalized for disease exacerbation were included in the analysis. Age at colectomy, preoperative days in the hospital, postoperative length of stay, and complications were recorded. The medical records were then reviewed for duration of disease, preoperative diagnosis, use of steroids and immunomodulators, parenteral nutrition, endoscopy findings, albumin level, postoperative diagnosis, and ultimate disposition. One hundred one patients underwent subtotal colectomy for inflammatory bowel disease during the study period. Seventy-four patients met all the inclusion criteria. The mean age was 35.9 (range, 18-86) years. Median duration of disease was 36 (0-240) months, but 28 patients had colitis for less than 1 year, whereas 10 patients had disease of greater than 10 years duration at the time of colectomy. Median preoperative hospital stay was 7 (range, 0-43) days and median postoperative length of stay was 6.5 (range, 4-37) days. Sixty-six patients underwent surgery for refractory exacerbation, 5 for free perforation, 2 for abscess, and 1 patient for hemorrhage. Twenty-seven patients (36.5 percent) had a change in diagnosis after surgery. Complications occurred in 17 patients (23 percent), including 8 cases of central venous catheter-associated thrombosis; 7 of these occurred in patients who had been hospitalized for more than a week before surgery. In the ulcerative colitis patients, 31 of 52 ultimately underwent ileal pouch-anal anastomosis, but 20 (39 percent) chose either completion proctectomy or no further surgery. Subtotal colectomy with ileostomy remains a safe and effective treatment for patients requiring urgent surgery for severe inflammatory bowel disease. Because of the substantial incidence of change in diagnosis and satisfaction in many patients with an ileostomy, subtotal colectomy with ileostomy may be preferable to primary ileal pouch-anal anastomosis, even when a pouch is considered safe.

Infliximab for the treatment of paediatric Crohn's disease: Obstacles to accessing a necessary therapy

The inflammatory bowel diseases (IBDs), comprising Crohn’s disease (CD) and ulcerative colitis (UC), are idiopathic chronic relapsing disorders of the gastrointestinal tract. Up to 25% of cases present during childhood and adolescence (1) and are associated with significant morbidity as manifested by debilitating symptoms, frequent hospitalizations, growth retardation and need for surgical interventions (2–6). Unfortunately, there is currently no cure (except at the cost of total colectomy and permanent ileostomy in UC) (7), and no single therapy is effective in controlling disease in all patients. As such, current therapeutic goals are directed at inducing remission during exacerbations and maintaining remission during quiescence while minimizing therapeutic side effects (8). Recent advances in our understanding of the underlying pathophysiology of IBDs have contributed to the development of novel pharmaceutical therapies for these disorders. Infliximab, a chimeric antibody targeted against tumour necrosis factor alpha, a key component in the inflammatory cascade, is one of the most recent therapies that has been proven to be efficacious in the treatment of CD (9,10). Unfortunately, numerous obstacles are encountered in obtaining access to this medication for paediatric patients who have failed multiple IBD therapies. These obstacles are not unique to paediatric patients with IBD but represent important issues facing the Canadian health care system’s ability to deliver appropriate care to our youth. As paediatricians and paediatric gastroenterologists, we believed it was important to highlight these issues (using infliximab as an example) to serve as a discussion point (Table 1).

Clinical results after restorative proctocolectomy without diverting ileostomy for ulcerative colitis.

This study evaluated the postoperative complications and clinical results of restorative proctocolectomy without diverting ileostomy for ulcerative colitis. One hundred selected patients had a hand-sewn ileal J-pouch anal anastomosis with mucosectomy using an ultrasonically activated scalpel. Three patients with pouch-related complications who needed diverting ileostomy. Five patients showed intestinal obstruction; two of the five needed relaparotomy and division of adhesions. The median number of bowel movements per 24 h was 6.5 (2-13) at 3 months and 5 (3-10) at 12 months. The corresponding nightly frequencies were 0 (0-5) at 3 months and 0 (0-3) at 12 months. After 3 months 82% of patients had no soiling during the daytime, and 45% were fully continent day and night. After 3 months 89% had recovered the ability to distinguish flatus from feces. Ileal pouch anal anastomosis can be performed safely without diverting ileostomy using an ultrasonically activated scalpel. The postoperative functional result was stabilized 3 months after the operation.

Antiperistaltic ileostomy using the long terminal ileal segment.

This study was undertaken to determine whether reversed terminal ileal segments can be used to decrease ileostomy output in patients who have undergone total proctocolectomy and ileostomy for ulcerative colitis or familial adenomatous polyposis. An approximately 25-cm length of terminal ileum was reversed in an antiperistaltic manner, and the new terminal ileal end was used for the ileostomy constructed in the usual manner. Six patients underwent this procedure and were compared with six patients who had conventional total proctocolectomy and ileostomy. Variables studied included weight of ileostomy output and the weight of the filtered fluid component. Data were obtained on seven different occasions during a two-month period beginning three months after the operation. Analysis was done using Student's t-test. There was a statistically significant decrease in the weight of the average 24-hour ileostomy effluent in those patients undergoing reversed antiperistaltic loop procedures. There was also a statistically significant decrease in the filterable liquid proportions. The antiperistaltic ileostomy is effective in reducing the daily amount of ileostomy effluent and facilitates stoma care, owing to its diminished liquid component.

Proctocolectomy and ileostomy to pouch surgery for ulcerative colitis.

The development of continence-preserving and sphincter-preserving procedures for operation of ulcerative colitis has a long and interesting history. Reported clinical results on the continent ileostomy (Kock pouch) and the pelvic pouch procedure have often been enthusiastic; and when confronted with the options patients have mostly been in no doubt in selecting "the best operation." However, even if the continent ileostomy and subsequently restorative proctocolectomy were great innovations, it is by no means obvious that they should be recommended as the first choice for all patients. For patients old enough to join in a responsible discussion the pros and cons of the various operations available today must first be carefully described and a decision reached that reasonably meets the patient's wishes and that seems to the surgeon to be soundly based. When comparing the postoperative morbidity, long-term outcome, and quality of life assessment of the options, such a decision is in fact far from easy. Thus panproctocolectomy and ileostomy for ulcerative colitis can be considered a comparatively safe, predictable operation that can cure the patient and allow a short hospital stay, a quick recovery, and rehabilitation. It should also enable the patient to be free of hospital supervision after a year or so. Although there is a major change in body image and sexual disturbances may occur, the operation is in fact still the yardstick by which the other options should be compared. Despite the great attraction of rectum- and sphincter-preserving operations, there will always be patients for whom panproctocolectomy and a conventional end-ileostomy is the superior alternative. The ileal pouch operations are technically demanding and should probably best be restricted to specialist centers even in the future. Complications, if they arise, are often serious, and the hospital stay is often counted in weeks. The functional result may be good, but defects in continence are common and sexual dysfunction is a problem for many of these patients. The pouchitis syndrome is a great disappointment, and recent reports on subsequent epithelial dysplasia and even development of cancer are alarming. The long-term results are in this respect still uncertain. Careful patient selection, with full discussion with the patient and his or her family are essential before a decision on a continent ileostomy or a pelvic pouch is reached. Strong motivation toward avoidance of a conventional ileostomy is important. When compared with the imperfect functional results and the high morbidity associated with the pelvic pouch procedure, there is at present a great revival of interest for total colectomy with ileorectal anastomosis. It is still a useful operation and should be seriously considered particularly in the young. The functional results are comparatively good. Sexual function is well preserved. The use of the operation may enable the teenager to regain good health and finish education and family planning. Due to the cancer risk the need for subsequent supervision must be made clear, however. The operation may also be valuable in elderly patients who would be much bothered by an ileostomy and who are unlikely to live long enough for carcinoma to become a problem. The great advantage is that should a failure occur the other options remain.

Apparent selective bile acid malabsorption as a consequence of ileal exclusion: effects on bile acid, cholesterol, and lipoprotein metabolism.

A new model has been developed to characterise the effect of a standardised ileal exclusion on bile acid, cholesterol, and lipoprotein metabolism in humans. Twelve patients treated by colectomy and ileostomy for ulcerative colitis were studied on two occasions: firstly with a conventional ileostomy and then three months afterwards with an ileal pouch operation with an ileoanal anastomosis and a protective loop ileostomy, excluding on average 95 cm of the distal ileum. The ileostomy contents were collected during 96 hours and the excretion of bile acids and cholesterol was determined using gas chromatography-mass spectrometry. Fasting blood and duodenal bile samples were collected on two consecutive days. After the exclusion of the distal ileum, both cholic and chenodeoxycholic acid excretion in the ileostomy effluent increased four to five times without any change in cholesterol excretion. Serum concentrations of lathosterol (a marker of cholesterol biosynthesis) and 7 alpha-hydroxycholesterol (a marker for bile acid biosynthesis) were increased several fold. Plasma concentrations of total VLDL triglycerides were also increased whereas the concentrations of total and LDL cholesterol, and apolipoprotein B were decreased. There were no changes in biliary lipid composition or cholesterol saturation of bile. The results show that the exclusion of about 95 cm of distal ileum causes malabsorption of bile acids but apparently not of cholesterol. The bile acid malabsorption leads to increased synthesis of both bile acids and cholesterol in the liver. It is suggested that bile acids can regulate cholesterol synthesis by a mechanism independent of the effect of bile acids on cholesterol absorption. The enhanced demand for cholesterol also leads to a decrease in plasma LDL cholesterol and apolipoprotein B concentrations. The malabsorption of bile acids did not affect biliary lipid composition or cholesterol saturations of VLDL triglycerides.

Peristomal pyoderma gangrenosum

Pyoderma gangrenosum (PG) is an idiopathic ulcerative skin disease that may be the cutaneous manifestation of many systemic diseases. Although the ulcers usually appear on the lower extremities, we report a case of peristomal pyoderma gangrenosum in a 25-year-old white female after proctocolectomy and ileostomy for ulcerative colitis. A total of 17 other cases of peristomal PG have been reported to date. In addition to the site of the ulcers, the case is remarkable because the patient was refractory to multiple trials of systemic therapy, including cyclosporine, until issues of local wound care were addressed. Effective local treatment was achieved using a calcium alginate dressing overlying pulverized sucralfate applied to the ulcers as well as enlarging the size of the ostomy bag opening. These local measures combined with systemic cyclosprine and prednisone led to complete ulcer healing in 9 weeks.

A Study of the Menopause in Women with Ulcerative Colitis

SummaryNinety-six of 102 women with ulcerative colitis diagnosed before the age of 35 years, 43 other women with an ileostomy for ulcerative colitis and 62 healthy women from South East Wales completed a questionnaire about their menstrual and menopausal history. By logistic analysis the age at the menopause of patients with ulcerative colitis was 49 ± 0.6 (s.e.) years compared to 50 ± 0.5 years in those with an ileostomy and 49 ± 0.1 years in the healthy controls. No difference between ages at the menopause between ulcerative colitis patients, those with an ileostomy and controls were found with the t test. This is in sharp contrast to Crohn's disease, where chronic disease is associated with a premature menopause.