Restorative Proctocolectomy For Ulcerative Colitis Research Articles

M1095 Is Ileoanal Pouch Surveillance Necessary to Detect Neoplasia After Restorative Proctocolectomy for Ulcerative Colitis?

The pathological signs of the disease showed strong correlation with the CDAI score in MREG (r =0.69). Conclusion: It has been observed that the MRI technique with oral contrast administration is an accurate tool in detecting inflammatory activity. The relatively safe contrast medium and a negligible radiation exposure are the main reasons why MREG should be used as a preferred method for monitoring of patients with Crohn's disease.

Adenocarcinoma complicating restorative proctocolectomy for ulcerative colitis with mucosectomy performed by Cavitron Ultrasonic Surgical Aspirator®

This is a report of adenocarcinoma arising in an ileal pouch after restorative proctocolectomy (RPC) with rectal mucosal stripping performed by Cavitron Ultrasonic Surgical Aspirator (CUSA) for ulcerative colitis. The CUSA was introduced to simplify and optimize ileal pouch-anal anastomosis with mucosectomy and has been shown to shorten the operative time and reduce blood loss. Its use however, may increase the number of pathology specimens made uninterpretable on account of tissue ablation. In the present case, even though preoperative colonoscopy had clearly shown dysplasia, the surgical pathology report could not detect any neoplasia in the specimen; hence, the patient was not surveyed for pouch cancer. Six years later, the patient presented with intestinal obstruction caused by cancer. While protocols for universal pouch surveillance remain somewhat controversial, we conclude on the basis of this case and a review of the literature that in RPC with mucosectomy performed by CUSA, pouch cancer surveillance is particularly important because remnants of rectal epithelium may have been left behind and tissue ablation may have made the surgical pathology report uninterpretable.

P065 - Medina catheter use following restorative proctocolectomy for ulcerative colitis: quality of life and functional outcome

P065 - Medina catheter use following restorative proctocolectomy for ulcerative colitis: quality of life and functional outcome

QS291. The Spectrum and Sequelae of Vascular Complications Following Restorative Proctocolectomy for Ulcerative Colitis

QS291. The Spectrum and Sequelae of Vascular Complications Following Restorative Proctocolectomy for Ulcerative Colitis

Endo‐sponge treatment of anastomotic leakage after ileo‐anal pouch anastomosis: report of two cases

The endo-sponge was used in two patients in the treatment of anastomotic leakage following ileo-anal J-pouch reconstruction. Recently, local vacuum sponge treatment has shown to be effective to treat contained anastomotic leakage after low anterior anastomosis in rectal cancer patients. Two patients (male, 18 years; female, 40 years) who underwent restorative proctocolectomy for ulcerative colitis developed localized anastomotic leakage without general peritonitis. This was endoscopically managed by transanal placement of an endo-sponge (B. Braun Medical B.V., Melsungen, Germany) after a diverting ileostomy was performed. The sponge was frequently replaced until resolution of the sinus was achieved in 35 and 56 days. Vacuum endo-sponge treatment can help anastomotic leakage after ileo-anal pouch surgery.

Predictors for acute and chronic pouchitis following restorative proctocolectomy for ulcerative colitis

This study was undertaken to evaluate the cumulative incidence, onset and risk predicting factors for acute and chronic pouchitis. A consecutive series of patients (n = 210), who underwent restorative proctocolectomy (RPC) and had a minimum follow-up of 12 months was reviewed. The cumulative incidence and onset of pouchitis was determined. Univariate analysis, followed by logistic regression analysis was used to evaluate the association of various demographic, clinical and histopathologic variables with the subsequent development of acute and chronic pouchitis. A total of 198 patients were included. The mean follow-up was 64 months (range, 12-180). Sixty-four patients (32%) developed pouchitis, 35 acute and 29 chronic. The first episode of pouchitis occurred within the first year in 70% of cases. The presence of backwash ileitis (OR, 2.6; P = 0.015), primary sclerosing cholangitis (PSC; OR, 2; P = 0.018) and the duration of follow-up (OR, 1.1; P = 0.043) were associated with a higher incidence of pouchitis. The duration of follow-up was the only variable associated with acute pouchitis (P = 0.007). The presence of backwash ileitis and PSC were independent risk factors for chronic pouchitis (OR, 5.9; P < 0.001; OR, 2.8; P = 0.001 respectively). Pouchitis is a heterogeneous disease which tends to occur early after restoration of gastrointestinal continuity. Patients with backwash ileitis and/or PSC are at considerable risk of developing chronic pouchitis. The strong association between backwash ileitis, PSC and chronic pouchitis suggests a common link in their pathogenesis.

Ileo-anal j-pouch cancer: an unusual case in an unusual location

Restorative proctocolectomy with ileal pouchanal anastomosis (IPAA) is the surgical treatment of choice for complicated ulcerative colitis. Development of ileal pouch-related cancer is a rare event and usually occurs in association with backwash ileitis or chronic pouchitis. We report a case of adenocarcinoma at the inlet of an ileal pouch in a 68-year-old Caucasian male, 14 years after restorative proctocolectomy for ulcerative colitis in the absence of severe chronic pouchitis or backwash ileitis. The operative technique is described, with a review of the literature on ileal pouch cancer.

Abnormal mucosal immune response to altered bacterial flora following restorative proctocolectomy in patients with ulcerative colitis: Serologic measures, immunogenetics, and clinical correlations

A patient from the University of North Carolina Hospitals is presented who developed Crohn's disease of the ileal J-pouch following restorative proctocolectomy for ulcerative colitis. Inflammation of the ileal pouch in human inflammatory bowel disease (IBD) represents the best clinical example of the importance of host–enteric microbial interactions, and this case highlights rapid advances in our understanding of the role of the enteric microbiota in the immunopathogenesis of IBD, impacting on clinical care. Successful management of this patient necessitated accurate diagnosis as there are several inflammatory and non-inflammatory conditions of the pouch that present with similar symptoms. Diagnostic measures included serologic assays of response to microbial antigens, including ASCA, anti-OmpC, anti-Cbir1, and pANCA with DNAse sensitivity. Although the serologic detection of selective loss of tolerance to microbial antigens defines clinically important subgroups of inflammatory bowel disease patients, the clinical value of these serodiagnostic tests is a matter of debate. Genome wide screens have also identified NOD2/CARD15, IL23 receptor, and ATG16L1 variants as important in IBD susceptibility and pathogenesis. These genetic associations have also provided new insights into the importance of interaction between the host and microbes in the pathogenesis of IBD, but the precise mechanisms by which these gene variants contribute to disease development remain to be determined. Genetic associations and serological markers will ultimately be used to define important clinical subgroups of disease, predict natural history, and ultimately identify patient populations for early therapeutic intervention.

Anterior Perineal PlanE for Ultra-low Anterior Resection of the Rectum (The APPEAR Technique)

The APPEAR procedure was developed to allow sphincter-preserving rectal resection for both benign and malignant pathology, which would traditionally require abdominoperineal excision or completion proctectomy, if treated by conventional means. This clinical trial (clinicaltrials.gov: NCT00534131) evaluated the short-term clinical and physiological results of this procedure. Fourteen patients were enrolled, 7 with neoplasia, 5 with ulcerative colitis, and 2 with traumatic rectal damage. Patients were evaluated preoperatively, and at a median of 2 years after surgery. Nine of 14 patients underwent ileostomy reversal and were followed up for a minimum of 1 year, with 1 patient awaiting closure. Four patients have not yet been considered for ileostomy reversal due to anastomotic perineal fistulae. Transient sexual dysfunction was noted in 3 of 14 patients, but no urological problems occurred. When the APPEAR procedure was performed for neoplasia or trauma, postoperative median Wexner continence score was 5 (range 0-8, n = 6), with a median defecation frequency of 3 (range 1-8/day). All cancers were completely excised with no local recurrence. Following APPEAR with restorative proctocolectomy for ulcerative colitis, median Wexner continence score was 2 (range 0-6, n = 3), with a median daily defecatory frequency of 3 (range 1-5). Preoperative SF-36 scores did not change significantly following ileostomy closure, and anorectal physiological testing was unaltered following perineal dissection. The APPEAR procedure provides an alternative technique to effect an ultra-low sphincter-saving anastomosis, when this is not possible by conventional surgery. Morbidity was encountered and greater experience will be required to fully assess this approach. Nevertheless, this is a promising new procedure with the potential to reduce the need for a permanent stoma even further than is currently the case.

Evaluation of vector manometry for characterization of functional outcome after restorative proctocolectomy

The impact of 3-dimensional vector manometry (VM) for characterization of the functional outcome of restorative proctocolectomy (RP) was studied in 61 patients at a median of 86 months after RP for ulcerative colitis. A 14-day continence diary was utilized to quantify continence, urgency, and the frequency of defecation. The clinical outcome data were correlated to the physiology parameters of VM and volumetry. VM parameters at rest correlated with postoperative continence but not substantially with stool frequency and urgency. High radial asymmetry was significantly correlated with the degree of incontinence (r=0.333, p=0.013). Resting pressures demonstrated a better correlation with the degree of incontinence when documented for the high-pressure zone (HPZ; portion of the sphincter with at least 50% of the maximum pressure; r=0.301, p=0.025) and when performed in the continuous pull-through technique. Stool frequency and urgency were better characterized by volumetry parameters like threshold volumes and pouch compliance. The specificity and sensitivity of the vector volume at rest of the HPZ for the prediction of incontinence was 63.6% and 59.1%, respectively. The corresponding values were 67% and 68%, respectively, for radial asymmetry at rest. Stool frequency and urgency were better characterized by volumetry parameters like threshold volumes and pouch compliance. A strong anal sphincter at rest and a consistent radial distribution of the sphincter pressure are the most reliable indicators of continence after RP obtained by VM, but their clinical usefulness is limited.

Adenocarcinoma Arising from the Rectal Stump Eleven Years after Excision of an Ileal J-Pouch in a Patient with Ulcerative Colitis: Report of a Case

Adenocarcinomas in relation to the ileal J-pouch after restorative proctocolectomy for ulcerative colitis have been recently reported with increasing frequency. All previously reported cases have occurred in patients with their ileal pouch in situ. We report a case of adenocarcinoma in the anal canal 11 years after removal of a failed ileal J-pouch. Mucosectomy had been performed at the restorative proctocolectomy. The anus had been left in place at the pouch excision because of severe fibrosis in the pelvis. If it is decided to remove an ileal pouch permanently, a total abdominoperineal excision should be performed, particularly in patients with risk factors for cancer development.

QS76. Is Fertility Affected in Female Patients After Restorative Proctocolectomy?

Introduction: Many females undergoing restorative proctocolectomy for ulcerative colitis or familial adenomatous polyposis are of child-bearing age. The purpose of this study was to evaluate the risk of infertility in women after major abdomino-pelvic surgery (restorative proctocolectomy with ileal pouch anal anastomosis) and to identify surgical factors that may affect post-operative fertility. Methods: A questionnaire inquiring as to both pre and post-operative fecundity was mailed to 186 female patients who were between the ages of 18 and 40 at the time of their restorative proctocolectomy surgery between 1985 and 2006.

Ileal pouch lymphoma following restorative proctocolectomy for ulcerative colitis

Ileal pouch lymphoma following restorative proctocolectomy for ulcerative colitis

Recent trends in the surgical management of inflammatory bowel disease

Surgery is required in the vast majority of patients with Crohn's disease (CD) and in approximately one-third of patients with ulcerative colitis (UC). Similar to medical treatments for IBD, significant advances have occurred in surgery. Advances in CD include an emphasis upon conservatism as exemplified by more limited resections, strictureplasties, and laparoscopic resections. The use of probiotics in selected patients has improved the outcome in patients with pouchitis following restorative proctocolectomy for UC. It is anticipated that ongoing discoveries in the molecular basis of IBD will in turn identify those patients who will best respond to surgery.

Adenocarcinoma after restorative proctocolectomy for cancer in ulcerative colitis

Dear Editor, Restorative proctocolectomy with creation of an ileal pouch-anal anastomosis is currently the procedure of choice for elective treatment of patients affected by ulcerative colitis with medically refractory disease, dysplasia or cancer. Although dysplastic transformation within the ileal pouch mucosa and in the rectal cuff in patients operated for ulcerative proctocolitis seems to be rare, 22 cases of adenocarcinoma adjacent to the ileo-anal anastomotic site after restorative proctocolectomy for ulcerative colitis have been described in literature so far. We report the case of a 52-year-old woman who was diagnosed with ulcerative colitis in 1980 at the age of 27. After the diagnosis, she required many hospital admissions for severe disease treated with sulphasalazine and steroids with good results. Past medical history also included a posttransfusional HCV infection treated in 2000 with interferon and ribavirin. In 2003, a colonoscopy revealed foci of adenocarcinoma and high-grade dysplasia in the descending and sigmoid colon. Consequently, the patient underwent restorative proctocolectomy with the formation of an ileal J pouch with double-stapled ileo-anal anastomosis. Histology of the surgical specimen revealed well-differentiated adenocarcinoma next to two non-invasive high-grade and low-grade lesions in the ascending colon; another welldifferentiated adenocarcinoma with necrotic areas was found in the transverse colon (G2T2N0M0). The rectum was clear of dysplasia or cancer. The phenotypic characterization of the lesions demonstrated <10% of neoplastic necrosis with no vascular nor perineural neoplastic invasion. No neoplastic lesions were found in the referred biopsy locations in the descending and sigmoid colon. Thirty-two months after the operation, a routine endoscopy showed a polipoid lesion at the anastomotic cuff in the anal transitional zone. Biopsies revealed high-grade dysplasia with foci of invasive adenocarcinoma. The patient underwent an abdominal–perineal resection with excision of the pouch and anus and formation of an end ileostomy. Surgical pathology evidenced a tubular-villous adenoma with predominant villous aspects; diffuse high-grade dysplasia and well-differentiated adenocarcinoma invading the stalk and into the submucosa of the bowel wall were demonstrated in association to a solitary ulcer and active ulcerative colitis (G1T1N0). Six months later the patient is doing well and is disease-free. Restorative proctocolectomy for patients with ulcerative colitis and co-existing colorectal cancer can be performed with a favourable prognosis and function. It is appropriate for curative intent, given that an adequate margin without tumour is obtained. Lee et al. reported three cases of adenocarcinoma after restorative proctocolectomy with a handsewn anastomosis adding to the 16, which had been previously reported. The authors noted that the overall incidence was extremely low and that the evidence to support surveillance was controversial with no clear defined dysplasia and carcinoma sequence. Factors that seemed to be related to the reported cases included a long history of antecedent ulcerative colitis (10–15 years), dysplasia or carcinoma in the original specimen, poor post-operative surveillance or severe or delayed presentation of pouchitis. Anal transitional zone dysplasia after ileal pouch-anal anastomosis is infrequent, usually self-limiting, most common in the first 2 to 3 years post-operatively and may Int J Colorectal Dis (2007) 22:1557–1558 DOI 10.1007/s00384-006-0269-4

Restorative Proctocolectomy for Ulcerative Colitis: Impact on Lipid Metabolism and Adipose Tissue and Serum Fatty Acids

The aim of this prospective study was to evaluate the changes of the metabolism of circulating and storage lipids in patients with ulcerative colitis after restorative proctocolectomy. Fifteen consecutive patients and 15 sex- and age-matched healthy controls were enrolled. Disease activity, diet, inflammatory parameters, plasma lipoprotein concentrations, and fatty acids (FA) of serum phospholipids and of the subcutaneous adipose tissue were assessed at colectomy and at ileostomy closure. In ulcerative colitis patients, total cholesterol and docosahexaenoic acid were lower than in healthy subjects (p < 0.01 and p < 0.05). The median interval between colectomy and ileostomy closure was 6 (range 2–9) months. During that interval, the inflammatory parameters improved, high-density lipoproteins (HDL) cholesterol increased (p < 0.01), and low-density (LDL) cholesterol decreased (p = 0.01). At ileostomy closure, serum arachidonic acid levels were increased (p = 0.04), whereas serum oleic acid level was decreased (p = 0.02). In this interval, no significant alteration, either in serum n-3 FA precursors or in the FA of subcutaneous adipose tissue, was observed. The increase of serum arachidonic acid after colectomy might suggest a lower utilization for inflammatory process. The reduction of LDL cholesterol is an index of malabsorption probably due to the accelerated transit and to the exclusion of the terminal ileum caused by the covering ileostomy.

Adenocarcinoma of the anal transitional zone after double stapled ileal pouch‐anal anastomosis for ulcerative colitis

The development of adenocarcinoma in the anal transitional zone, after restorative proctocolectomy for ulcerative colitis, is rare. We report the first Asian and sixth known case. A 41-year-old Indian lady had a long standing history of ulcerative colitis. Restorative proctocolectomy and stapled ileal pouch-anal anastomosis without mucosectomy was performed. She remained asymptomatic until 3 years later when she complained of discomfort on defecation. A poorly differentiated adenocarcinoma in the anal transition zone was diagnosed and she subsequently underwent an abdomino-perineal resection. The previously reported cases in the literature are reviewed. We also discuss the suggested surveillance for high-risk patients who have undergone an ileal-anal pouch anastomosis.

Risk of dysplasia and adenocarcinoma following restorative proctocolectomy for ulcerative colitis

Risk of dysplasia and adenocarcinoma following restorative proctocolectomy for ulcerative colitis

Adenocarcinoma Arising Below an Ileoanal Anastomosis After Restorative Proctocolectomy for Ulcerative Colitis: Report of a Case

We report a case of adenocarcinoma developing in remnant rectal mucosa below a hand-sewn ileal pouch-anal anastomosis (IPAA) after restorative proctocolectomy for ulcerative colitis (UC). To our knowledge, this is the first such case to be reported from Japan. A 60-year-old man with a 13-year history of UC underwent proctocolectomy with a hand-sewn IPAA and mucosectomy for anal stenosis and serious tenesmic symptoms. About 7 years later, a follow-up endoscopy showed a flat elevated malignant lesion, 2 cm in diameter, below the ileoanal anastomosis. He was treated by abdominoperineal resection of the pouch and anus with total mesorectal excision. Histopathological examination of the resected specimen confirmed the presence of a well-differentiated adenocarcinoma but there were no metastatic lymph nodes. He recovered uneventfully and remains well without evidence of recurrent disease 2 years and 3 months after his last operation.

The Effect of Restorative Proctocolectomy on Sexual Function, Urinary Function, Fertility, Pregnancy and Delivery: A Systematic Review

This study was designed to evaluate the effect of restorative proctocolectomy on sexual function, urinary function, fertility, pregnancy, and delivery in patients with ulcerative colitis. A systematic literature search was performed of articles published between 1980 and 2005 on patients undergoing restorative proctocolectomy for ulcerative colitis reporting data on the outcomes of interest. A random-effect, meta-analytical model was used for pooled estimates and 95 percent confidence intervals. A total of 22 studies, with 1,852 females, were included. Infertility rate was 12 percent before restorative proctocolectomy and 26 percent after, among 945 patients in seven studies. The incidence of sexual dysfunction was 8 percent preoperatively and 25 percent postoperatively (7 studies, n = 419). Two studies (n = 62) reported no urinary dysfunction in patients undergoing restorative proctocolectomy. There was an increased incidence of cesarean section after restorative proctocolectomy. During the third trimester of pregnancy, there was an increase in stool frequency by 1.15 stools per day compared with before pregnancy frequency (n = 49 95 percent confidence interval, 0.28-2.03 P = 0.01 chi-squared statistic, 0.04 P = 0.84). No significant differences were seen in pouch function after vaginal delivery (n = 456; weighted mean difference, 0.23; 95 percent confidence interval, 0.43-0.88; P = 0.49; chi-squared statistic, 1.29; P = 0.26). The incidence of dyspareunia increases after restorative proctocolectomy. There was a decrease in fertility after restorative proctocolectomy. Pregnancy after restorative proctocolectomy was not associated with an increase in complications. There was an increase in stool frequency and pad usage during the third trimester. Vaginal delivery is safe after restorative proctocolectomy. Pouch function after delivery returns to pregestational function within six months.