Proctocolectomy For Ulcerative Colitis Research Articles

Colonic Metaplasia of Ileostomies

Two patients who had undergone proctocolectomy for ulcerative colitis developed lesions in their ileal stoma that appeared to be inflammatory polyps morphologically similar to those encountered in the large intestine of ulcerative colitis patients. One of these patients eventually developed mucinous adenocarcinoma in the ileal stoma. The ileal mucosa adjacent to the neoplasm had morphologic features of large-bowel mucosa and was richly populated by sulfomucin-containing goblet cells, which are characteristic of large-bowel mucosa. Sulfomucin-containing goblet cells were also found in the inflammatory lesions biopsied from the ileal stomas of both patients, as well as from the adenocarcinoma found in one patient. These findings support the hypothesis that colonic metaplasia can occur in ileal stomas of ulcerative colitis patients. Furthermore, the metaplastic colonic tissue is the site of origin of lesions typically found in ulcerative colitis. Colonic metaplasia occurring in ileal stoma should be recognized by pathologists as a clinical entity. When colonic metaplasia is identified in the ileal stoma of an ulcerative colitis patient, biopsy surveillance of stomal mucosa is recommended.

Ileal ecology after pouch-anal anastomosis or ileostomy: A study of mucosal morphology, fecal bacteriology, fecal volatile fatty acids, and their interrelationship

Ileal mucosal morphology, fecal bacteriology, fecal volatile fatty acids, and their interrelationships were studied in 15 patients with an ileal pouch-anal anastomosis and 14 patients with an ileostomy after proctocolectomy for ulcerative colitis. Pouch effluent, compared with ileostomy effluent, had a greater ratio of anaerobes to aerobes (p < 0.05), and greater numbers of Bacteroides (p < 0.01) and Bifidobacteria (p < 0.05). Fecal volatile fatty acids, products of anaerobic bacterial fermentation, were also increased in pouch effluent compared with ileostomy effluent (propionate, p < 0.05; butyrate, p < 0.01). Mucosal inflammation and villous atrophy were more severe in the pouches than in ileostomies (p < 0.01). Mucosal change in the pouches showed no significant correlation with frequency of defecation, completeness of emptying, or pouch design, but the degree of villous atrophy was correlated with the number of Bacteroides (rs = − 0.93, p < 0.01) and with fecal butyrate (rs = 0.68, p < 0.05). Fecal propionate was significantly correlated with the percentage of stool retained after defecation (rs = 0.82, p < 0.01). These findings indicate that the bacterial ecology of ileal pouches has an important influence on the morphology of their mucosal lining.

Ileal Ecology After Pouch-Anal Anastomosis or Ileostomy: A Study of Mucosal Morphology, Fecal Bacteriology, Fecal Volatile Fatty Acids, and Their Interrelationship

Ileal mucosal morphology, fecal bacteriology, fecal volatile fatty acids, and their interrelationships were studied in 15 patients with an ileal pouch-anal anastomosis and 14 patients with an ileostomy after proctocolectomy for ulcerative colitis. Pouch effluent, compared with ileostomy effluent, had a greater ratio of anaerobes to aerobes (p less than 0.05), and greater numbers of Bacteroides (p less than 0.01) and Bifidobacteria (p less than 0.05). Fecal volatile fatty acids, products of anaerobic bacterial fermentation, were also increased in pouch effluent compared with ileostomy effluent (propionate, p less than 0.05; butyrate, p less than 0.01). Mucosal change in the pouches showed no significant correlation with frequency of defecation, completeness of emptying, or pouch design, but the degree of villous atrophy was correlated with the number of Bacteroides (rs = 0.93, p less than 0.01) and with fecal butyrate (rs = 0.68, p less than 0.05). Fecal propionate was significantly correlated with the percentage of stool retained after defecation (rs = 0.82, p less than 0.01). These findings indicate that the bacterial ecology of ileal pouches has an important influence on the morphology of their mucosal lining.

Ileoproctostomy with J-pouch: Use of the swenson pull-through forreconstruction after proctocolectomy for ulcerative colitis

Continence can be preserved by several operations following proctocolectomy for ulcerative colitis. The Swenson procedure, used for congenital megacolon, may be applied for reconstruction following proctocolectomy for other colonic disease. Rectal eversion and resection to the dentate line obviates the need for mucosectomy and permits ileoanal anastomosis with excellent exposure. Two girls, 9 and 11 years of age, underwent proctocolectomy, formation of an ileal J-pouch, and a Swenson pull-through with ileoanal anastomosis. One year following closure of diverting ileostomies, both children have 2 to 3 continent bowel movements daily with very rare nocturnal soiling. Anal manometry is normal. The application of this method for ileoanal anastomosis may broaden the choice of operations for selected children requiring proctocolectomy.

Water and electrolyte balance in subjects with a permanent ileostomy.

Water and electrolyte balance has been studied in 39 patients with a permanent ileostomy, who had had a proctocolectomy for ulcerative colitis. The findings have been compared with those in 39 healthy subjects who were matched for age and sex. The ileostomists were found to lose excessive quantities of water and sodium in the ileostomy effluent compared with the corresponding losses in normal faeces. The mean plasma total protein and albumin concentrations were increased in the ileostomists suggesting a state of chronic dehydration. The daily urinary output of sodium was low and the output of potassium was high. The urinary pH was low. The ileostomists had raised mean concentration of aldosterone in the plasma (p less than 0.001) and it is suggested that this is responsible for the body's partial compensation for the depletion of sodium and water, including the so-called ileostomy adaptation.

Calcium metabolism in subjects living with a permanent ileostomy.

Several indices of calcium metabolism have been studied in 39 subjects living with a permanent ileostomy after proctocolectomy for ulcerative colitis, and in a control group of 39 healthy volunteers, matched for age and sex. No significant differences were found in plasma levels of calcium, phosphate, magnesium, parathyroid hormone, calcitonin and 25-hydroxy-vitamin D nor in the urinary excretion of calcium and phosphate, but the alkaline phosphatase was raised in the ileostomists. The bone density of the ileostomists was rather low, but the difference from the control subjects was not statistically significant. The absorption of calcium was measured by means of a total body counter. The ileostomists retained significantly more calcium than expected. It is suggested that this may represent the correction of a state of calcium deficiency at the time of proctocolectomy, due to the effects of the colitis and its medical treatment with corticosteroids.

Adenocarcinoma of an Ileostomy Site With Skin Invasion: A Case Report

A case is reported of an adenocarcinoma arising in an ileostomy site 32 yr after a staged proctocolectomy for ulcerative colitis. As in 2 of the 3 previously reported cases of Ileostomy carcinoma, a locally invasive tumor produced Ileostomy retraction and stenosis with peristomal pain and ulceration but no intestinal obstruction or metastatic spread. When an ileostomy requires late revision for inflammatory changes, careful pathologic examination of the entire resected stoma and surrounding skin is essential.

Proctocolectomy for ulcerative colitis.

The majority of patients with ulcerative colitis can be managed satisfactorily throughout their lives by medical treatment, but a minority require colectomy. In severe attacks, emergency surgery is often required to save the patient's life. In chronic disease not responding well to medical treatment, elective colectomy will restore the patient to good health. Colectomy is also necessary for certain local complications, such as cancer, severe fistulas, and strictures. Prophylactic colectomy is indicated in patients with long-standing disease in whom there are factors associated with a high risk of developing cancer of the large bowel. For all these indications, it is our opinion that single-stage proctocolectomy is the operation of choice in the great majority of patients. Finally, we consider that the best results are obtained when the physician and the surgeon work together in the closest possible cooperation.

The continent ileostomy

The continent ileostomy has significantly improved the quality of life in selected patients. This procedure may be useful for patients who need total proctocolectomy for ulcerative colitis or familial polyposis or who have complications from conventional ileostomies. It should be performed only by experienced intestinal surgeons who are willing to accept the long-term commitment of treating these patients and their numerous complications. It is recommended with cautious optimism for selected patients.

Reversed Ileal Segment for Treatment of Ileostomy Dysfunction

Persistent, profuse ileostomy diarrhea developed gradually in a patient over a 12-hour period after proctocolectomy for ulcerative colitis. There was no evidence of ileostomy stenosis or dilation of the ileum proximal to the stoma. He was successfully treated with a reverse ileal segment of 10 cm, and gained 14 to 18 kg. ileostomy output became semisolid and decreased from 1,000 to 2,000 ml/day to 600 ml/day. The transit time changed from 12 minutes to 2 1/2 hours. Antiperistaltic segments of intestine prolong transit time and allow for greater absorption. While most patients with ileostomies are not troubled by severe diarrhea, the small proportion who are may be candidates for a reversed ileal segment.

The hazards of a permanent ileostomy.

Among the considerations in making the decision for proctocolectomy in ulcerative colitis is the hazard of ileostomy. Since our current techniques for constructing an ileostomy were developed less than 20 years ago, the long-term risks associated with a permanent ileal stoma cannot yet be assessed. Nevertheless, periodic follow-up information on ileostomy patients is of value when operation is being considered for a patient with chronic ulcerative colitis. In this report attention has been focused on the frequency and type of ileostomy complications which require a corrective operation. Material The case histories of all patients who had a permanent ileostomy established during the 20-year period ending Dec 31, 1967, were reviewed. Patients in whom the ileal stoma was constructed because of chronic ulcerative colitis were selected for study. Cases in which the ileal stoma was made because of granulomatous colitis were excluded. Using these criteria a total of 88 cases were