Time Of Ileal Pouch-anal Anastomosis Research Articles

Does the age of ulcerative colitis diagnosis impact outcomes of restorative proctocolectomy?

Ulcerative colitis (UC) can be diagnosed at a variety of different ages. We evaluated if age of ulcerative colitis (UC) diagnosis impacts outcomes of restorative proctocolectomy (RP) with ileal pouch-anal anastomosis (IPAA). A prospectively maintained pouch database (1983-2020) was queried to identify patients undergoing an RP for UC. The cohort was stratified based on bimodal disease presentation into 2 groups: the early adulthood group (19-30years old) and the mid/late adulthood group (40-70years old). Patients' demographics, postoperative complications, functional (stool number, seepage), and quality of life (QoL) rates were compared between the groups. A total of 628 patients with an age range of 19-30years old (18.1 ± 2.2 at the time of diagnosis, 24.2 ± 10.5 at the time of IPAA) and 706 patients with an age range of 40-70years old (45 ± 3.0 at time of diagnosis, 52.3 ± 9.4 at time of IPAA) were identified. Older patients had longer disease duration, higher BMI, lower biologic use, and greater one-/two-staged IPAA, with 20% hand sewn anastomosis and 16.5% of S pouch configuration compared to younger ones. No difference was observed in anastomotic separation, pelvic sepsis, fistulas, or pouch failure in follow-up. Postoperatively, older patients more frequently developed bowel obstructions, strictures, and pouchitis, in addition to higher rates of seepage (p < 0.05). QoL was comparable between groups. While IPAA retention rates are comparable between different age cohorts, older age at diagnosis and IPAA construction is associated with higher rates of pouchitis, bowel obstruction, anastomotic strictures, and worse functional outcome. Quality of life is similar in those who retain their ileal pouch on the long-term.

The Role of Diversion During Ileal Pouch Anal Anastomosis (IPAA) Creation in Pediatric Ulcerative Colitis

IntroductionIn pediatric ulcerative colitis (UC), surgery is often postponed until disease is life-threatening or refractory to immune suppression. In these settings, diverting ileostomy (DI) is theorized to have a protective effect on the new anastomosis. However, analyses have been performed only in single-institution series and the true impact of performing DI at the time of IPAA on postoperative outcomes is unclear. MethodsWe performed a retrospective cohort study using claims data from the International Business Machines (IBM) MarketScan® database. Patients were sorted to the DI group if they carried a CPT code for ostomy closure within 6 months of index procedure. We examined demographics, preoperative risk factors, and performed regression analysis to compare 30-day postoperative outcomes between groups. ResultsWe identified 317 patients ≤18yo that underwent IPAA procedure and met inclusion criteria from 2000 to 2019. Of these, 238 patients were assigned to the IPAA + DI cohort and 79 patients were assigned to the IPAA cohort.Adverse outcomes were comparable between cohorts. Surgical site infection (SSI) rates between IPAA and IPAA + DI were 10.1 vs. 11.3% (p = 0.67). Rates of intra-abdominal drainage procedures were 3.8 vs. 2.1% (p = 0.39). The rates of 30-day readmissions were 16.5 vs. 19.3% (p = 0.39). Creation of a DI was not associated with higher odds of 30-day readmission (OR = 1.4, p = 0.31). ConclusionCreating a DI necessitates an additional surgery for closure and is not associated with decreased adverse outcomes. There is still a role for multicenter studies to define which patient populations may benefit from diversion. Level of EvidenceRetrospective comparative study. Type of StudyLevel III.

Prolonged diversion after ileal pouch-anal anastomosis: Is it safe to wait?

Diverting loop ileostomy reversal (DLI-R) is routinely performed from 2-6months following ileal pouch-anal anastomosis (IPAA). The safety of delayed reversal after IPAA is not well-defined. The aim of this study was to determine if prolonged diversion is associated with adverse outcomes compared to routine closure. Adult patients undergoing primary IPAA with DLI from 2000 to 2021 were included in this retrospective cohort study from our institutional database. Patients were stratified into tertiles based on timing of reversal: Routine (56-116 days), Delayed (117-180 days), or Prolonged (>6months). Univariate analysis compared categorical variables between groups. Patients reversed at <8 weeks were excluded. In total, 2615 patients underwent DLI-R following IPAA (3-stage 61%, 2-stage 39%; mean age 39.9 years). DLI-R was performed as Routine, Delayed and Prolonged in 1908 (72.9%), 426 (16.4%) and 281 (10.8%), respectively. Overall, DLI-R related complications occurred in 12.4% (n=324). The complication rate in the Routine group was 11% (n=210), in the Delayed group was 12.2% (n=52) and in the Prolonged group was 22.1% (n=62). Reasons for prolonged diversion in the Prolonged group were complications at the time of IPAA in 207 (73.9%) or patient preference/scheduling in 73 (26.1%). DLI-R >6months after IPAA due to complications had higher rates of overall complications following ileostomy reversal (OR 2.6, 95% CI 1.85-3.72, p < 0.001) whereas when DLI-R was delayed due to preference/scheduling outcomes were not different than the Routine group (p=0.28). Prolonged time to ileostomy reversal after IPAA is probably safe without increased risk of complications when due to patient preference.

Inflammation of the rectal remnant endangers the outcome of ileal pouch-anal anastomosis: a case–control study

BackgroundInflammation of the rectal remnant may affect the postoperative outcome of ileal pouch-anal anastomosis (IPAA) in patients with ulcerative colitis (UC). We aimed to determine the extent of inflammation in the anastomotic area during IPAA and to investigate the impact of proctitis on postoperative complications and long-term outcomes.MethodsThree hundred thirty-four UC patients with primary IPAA were included in this retrospective case–control study. The histopathologic degree of inflammation in the anastomotic area was graded into three stages of no proctitis (“NOP”), mild to medium proctitis (“MIP”), and severe proctitis (“SEP”). Preoperative risk factors, 30-day morbidity, and follow-up data were assessed. Kaplan–Meier analysis was performed in the event of pouch failure.ResultsThe prevalence of proctitis was high (MIP 40.4%, and SEP 42.8%). During follow-up, the incidence of complications was highest among SEP: resulting in re-intervention (n = 40; 28.2%, p = 0.017), pouchitis (n = 36; 25.2%, p < 0.01), and pouch failure (n = 32; 22.4%, p = 0.032). The time interval to pouch failure was 5.0 (4.0–6.9) years among NOP, and 1.2 (0.5–2.3) years in SEP (p = 0.036). ASA 3, pouchitis, and pouch fistula were independent risk factors for pouch failure.ConclusionProctitis at the time of IPAA is common. A high degree of inflammation is associated with poor long-term outcomes, an effect that declines over time. In addition, a higher degree of proctitis leads to earlier pouch failure.

Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: An Australian Institution's Experience.

PurposeWe report outcomes and evaluate patient factors and the impact of surgical evolution on outcomes in consecutive ulcerative colitis patients who had restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) at an Australian institution over 26 years.MethodsData including clinical characteristics, preoperative medical therapy, and surgical outcomes were collected. We divided eligible patients into 3 period arms (period 1, 1990 to 1999; period 2, 2000 to 2009; period 3, 2010 to 2016). Outcomes of interest were IPAA leak and pouch failure.ResultsA total of 212 patients were included. Median follow-up was 50 (interquartile range, 17 to 120) months. Rates of early and late complications were 34.9% and 52.0%, respectively. Early complications included wound infection (9.4%), pelvic sepsis (8.0%), and small bowel obstruction (6.6%) while late complications included small bowel obstruction (18.9%), anal stenosis (16.8%), and pouch fistula (13.3%). Overall, IPAA leak rate was 6.1% and pouch failure rate was 4.8%. Eighty-three patients (42.3%) experienced pouchitis. Over time, we observed an increase in patient exposure to thiopurine (P = 0.0025), cyclosporin (P = 0.0002), and anti-tumor necrosis factor (P < 0.00001) coupled with a shift to laparoscopic technique (P < 0.00001), stapled IPAA (P < 0.00001), J pouch configuration (P < 0.00001), a modified 2-stage procedure (P = 0.00012), and a decline in defunctioning ileostomy rate at time of IPAA (P = 0.00002). Apart from pouchitis, there was no significant difference in surgical and chronic inflammatory pouch outcomes with time.ConclusionDespite greater patient exposure to immunomodulatory and biologic therapy before surgery coupled with a significant change in surgical techniques, surgical and chronic inflammatory pouch outcome rates have remained stable.

The effect of diversion on readmission following ileal pouch-anal anastomosis in children

BackgroundReadmission rates as high as 20% have been reported after ileal pouch-anal anastomosis (IPAA) in children, with obstruction and dehydration as the most commonly listed reasons. We hypothesized that a diverting ileostomy contributes to unplanned readmission after IPAA creation. MethodsChildren (age <18) who underwent IPAA creation from January 2007 to August 2018 at two affiliated institutions were reviewed. Patient demographics, operative details, and post-operative length of stay (LOS) were abstracted. Unplanned readmission within 30 days and details on patient readmission were reviewed. ResultsNinety-three patients (57% female) with a median age of 15 years (range: 18 months-17 years) underwent IPAA. Indications for IPAA included ulcerative colitis (n = 63; 68%), familial adenomatous polyposis (n = 24; 26%), indeterminate colitis (n = 5; 5%), and total colonic Hirschsprung's (n = 1; 1%). Sixty-one (66%) patients were diverted at the time of IPAA creation.Fourteen patients (15%) were readmitted, and reasons for readmission included bowel obstruction (n = 9; 64%), dehydration (n = 2; 14%), anastomotic leak (n = 2; 14%), and gastrointestinal (GI) bleeding (n = 1; 6%). Patients with a diverting ileostomy at the time of IPAA were more often readmittted than patients who were not diverted (21% vs 3%, p = 0.03). Further, 10 (71%) of the readmitted patients had complications attributable to their ileostomy. In patients readmitted for obstructive symptoms, six (67%) required red rubber catheter insertion for resolution, two (22%) patients required reoperation for obstructions at the level of the stoma, and one (11%) resolved with bowel rest alone. ConclusionReadmission following IPAA creation in children is often secondary to preventable issues related to diverting ileostomy. Surgeons should carefully consider the necessity of diversion. When it is necessary, particular attention to fascial aperture size and post-discharge initiatives to reduce dehydration may reduce readmission rates. Level of EvidenceLevel III.

P048 Type and durability of antibiotic therapy among patients with chronic antibiotic dependent pouchitis

BACKGROUND: The management of chronic antibiotic dependent pouchitis (CADP) is associated with significant morbidity and burden to patients with an ileal pouch-anal anastomosis (IPAA). When individuals fail to respond to standard antibiotic therapy for pouchitis, little guidance is available in choosing subsequent antibiotic regimens. We performed a retrospective study to evaluate specific antimicrobials as well as duration of therapy among patients treated for CADP in our multidisciplinary IBD center. METHODS: We identified patients with CADP between January 1, 2009 and December 1, 2016. Patients diagnosed with Crohn’s disease of the pouch and acute antibiotic responsive pouchitis were excluded. For each individual with CADP, we analyzed the type and duration of up to 4 antibiotic regimens. Standard descriptive statistics are presented, including medians and interquartile ranges (IQR) for duration assessments and Wilcoxon-rank sum testing for comparisons of duration of antibiotic therapy. RESULTS: A total of 288 patients were evaluated for pouch related disorders during the study period. From the initial population, 90 (31%) were excluded due to a diagnosis of Crohn's disease of the pouch and 75 (26%) were excluded due to a diagnosis of acute antibiotic responsive pouchitis. In total, there were 123 patients (53% male, mean age at time of IPAA 40.9 years) who were diagnosed with CADP. Most patients underwent a 2-stage IPAA and had pancolitis prior to colectomy. In the majority of patients (93/123; 75%), the first antibiotic regimen consisted of a fluoroquinolone alone (43%) or a fluoroquinolone in combination with either metronidazole (30%) or another antibiotic (2%). Metronidazole was used in 15%, and other antibiotics in 10% of the patients. Of the 123 patients, 93%, 76%, and 59% needed a second, third, or fourth antibiotic regimen, respectively. The use of fluoroquinolones alone or in combination decreased to 54%, 48%, and 40% of patients for the second, third, and fourth regimen. In particular, amoxicillin/clavulanate, sulfamethoxazole/trimethoprim, rifaximin and doxycycline were increasingly used in the third and fourth antibiotic approach (31% and 42%, respectively). The duration of the different antibiotic regimens varied, but fluoroquinolones alone were given for a significantly longer duration during the first 4 consecutive regimens compared to other antibiotics indicating a better persistence of therapy (regimen 1 median fluoroquinolone duration 32 weeks vs others 7.5 weeks (IQR 4–36), P &lt; 0.001; regimen 2 median 20 weeks vs 8 weeks (IQR 4–28), P = 0.038; regimen 3 median 21 weeks vs 8 weeks (IQR 4–36), P = 0.005; regimen 4 median 20 weeks vs 10 weeks (IQR 4–20), P = 0.011). CONCLUSION(S): In a retrospective cohort of patients with CADP, we found that standard therapy with a fluoroquinolone alone or in combination was most common as the initial treatment for CADP. Although fluoroquinolones in particular demonstrated significant longevity, over time the proportion of the population treated with alternative antibiotic regimens such as amoxicillin/clavulanate, sulfamethoxazole/trimethoprim, doxycycline, and rifaximin increased presumably due to loss of response to standard therapy. Further studies are needed to individualize the therapeutic approach and determine the optimal antibiotic regimen with greatest durability and long-term response for this challenging patient population.

Laparoscopic restorative proctocolectomy technical notes and postoperative results

Laparoscopic colon surgery has become a proved method for the resection of both benign and malignant disease. With the advance of technological innovations and surgical experience, more complex laparoscopic procedures including restorative proctocolectomy have become increasingly used in the treatment of ulcerative colitis with safe and feasible results. When these operations are realized in a stepwise fashion, the complexity of the procedure becomes simplified. The technical aspects of laparoscopic restorative proctocolectomy in patients with ulcerative colitis are reviewed in this article. A J-pouch with a stapled anastomosis has been the preferred technique because it is quicker and safer. In all patients diverting loop ileostomy is regularly created at the time of ileal pouch-anal anastomosis. In this review the postoperative results are also revised. Postoperative fasting time, postoperative hospital stay, and overall complication rate are in favor of laparoscopic technique when compared to open approach. However, clinical value of laparoscopic surgery for ulcerative colitis needs further evaluation with more well-designed randomized controlled trials along with long-term follow-up.

Variation in Recommendations for Modes of Delivery Post Ileal Pouch-Anal Anastomosis (IPAA) in Women with Ulcerative Colitis

Purpose: Fertility may be negatively affected in women with ulcerative colitis (UC) after ileal pouch-anal anastomosis (IPAA). However, it is unclear whether women who do conceive after IPAA should undergo vaginal delivery or cesarean section (CS). There are no formal consensus guidelines in this setting among gastroenterologists (GI), colorectal surgeons (CRS) and obstetricians (OB) who often co-manage these patients. This can lead to variation in care, a marker of poor quality. Furthermore, contrasting recommendations by different specialists may be confusing for the patient. Aim: To determine if there is variation among physicians in their recommendations for mode of delivery post-IPAA in a cohort of female UC patients. Methods: A total of 105 patients of child-bearing age at the time of IPAA (18-44 years old) performed by a single surgeon were surveyed via telephone and/or email using a survey instrument developed with input from GIs (n=2) and CRS (n=1) with expertise in IBD. Survey questions included patient demographics, IBD and surgical history, pregnancy history including any infertility work-up, recommendations regarding modes of delivery and delivery history. Results: A total of 44 (42%) patients (mean age; 38 years) specifically answered the survey question regarding mode of delivery recommended by their physicians (OB, High-risk OB, Midwife, GI, CRS). Half of these patients stated they did not discuss this with their physicians as they had no immediate plans (45%) or future plans (55%) for pregnancy post IPAA. Of the 22 seeking a recommendation, all 17 patients who asked their CRS were recommended to undergo CS. Twelve patients also asked a total of 16 OBs; 10 recommended vaginal delivery, 5 recommended CS, and 1 deferred recommendation until a later date. Four patients asked their GI doctor; 2 recommended CS and 2 were given no recommendation. One patient also asked a midwife, who recommended vaginal delivery. Seven had 13 full-term pregnancies; 6 women had a total of 9 CS, and 1 had a total of 4 vaginal deliveries. Of the 15 women who had not yet conceived, 5 were undergoing infertility work-up and 10 had electively deferred conception. However, at the time of a potential future pregnancy, 8 would elect for CS based on previous CRS recommendation, 1 would elect for vaginal delivery despite a CS recommendation and 6 were undecided. Conclusion: In our cohort, there was disconcordance between CRS and OB recommendations for mode of delivery post-IPAA. Patients tended to follow the recommendation of the CRS more than the OB. A study is underway to further examine variation in recommendations among different specialties managing women with IBD of childbearing age pre- and post-IPAA.

Technical Aspects of Ileoanal Pouch Surgery in Patients with Ulcerative Colitis

Restorative proctocolectomy with ileal pouch-anal anastomosis is the procedure of choice for patients with ulcerative colitis requiring surgery. A J-pouch with a stapled anastomosis has been the preferred technique because it is quicker, safer, and associated with good functional outcomes. A diverting loop ileostomy is usually created at the time of ileal pouch-anal anastomosis. In patients with severe fulminant colitis or toxic megacolon, restorative proctocolectomy with ileal pouch-anal anastomosis is performed in multistages. The technical aspects of ileal pouch-anal anastomosis in patients with ulcerative colitis are reviewed in this article.

Quality of Life Ten and More Years After Restorative Proctocolectomy for Patients With Familial Adenomatous Polyposis Coli

Few studies on long-term quality of life after restorative proctocolectomy and ileal pouch-anal anastomosis have been published. Most of them survey a mixed patient population of familial adenomatous polyposis and ulcerative colitis. The present study analyzes long-term results more than 10 years after ileal pouch-anal anastomosis for patients with familial adenomatous polyposis, exclusively. One hundred thirty-five patients who underwent ileal pouch-anal anastomosis more than 10 years ago were identified from the prospective familial adenomatous polyposis registry at Heidelberg University hospital. They received the German version of the health-specific Short Form 36 Health Survey and the disease-specific Gastrointestinal Quality of Life Index by mail. To assess the impact of disease-specific factors, 10 questions asking for ability to work, current medication, pouchitis, and extracolonic manifestations of familial adenomatous polyposis were added to the Gastrointestinal Quality of Life Index questionnaire. Among 84 patients who answered the questionnaires the median follow-up was 13.4 years (range, 10.3-23.8 y).The results of the Short Form 36 Health Survey were comparable to a German normative population in all dimensions, whereas the overall score for the Gastrointestinal Quality of Life Index was significantly reduced compared with healthy individuals (111.8 vs 120.8, P = .0014). Carcinoma at the time of ileal pouch-anal anastomosis, desmoid tumors, or duodenal adenomas had no significant influence on quality of life. More than 7 bowel movements during the daytime were found to reduce quality of life significantly (103.5 vs 115, P = .0127). More than 2 defecations per night diminished the score further (101 vs 125, P < .0001). Patients younger than 40 years at the time of ileal pouch-anal anastomosis had significantly better results than older patients (120 vs 109.5, P = .0076). Ileal pouch-anal anastomosis is a safe surgical procedure with a high quality of life comparable to that of a normative population after long-term follow-up of patients with familial adenomatous polyposis.

Do outcomes differ after 3-Stage versus 2-Stage Ileal Pouch-Anal Anastomosis for chronic Ulcerative Colitis?

Given concerns of increased post-operative complications associated with anti-TNF-alpha antibody therapy, some surgeons are increasingly offering patients with chronic ulcerative colitis (CUC) a 3-stage approach to ileal pouch-anal anastomosis (IPAA). We aimed to assess outcomes after the 1st of 2-stages compared with the 2nd of 3-stages in a cohort of patients who underwent hand-assisted laparoscopic surgery (HALS). We identified all adult patients with CUC who underwent total proctocolectomy (TPC-IPAA, stage 1 of 2) and patients who underwent completion proctectomy (CP-IPAA, stage 2 of 3) at our institution from 2004 - 2009 using a prospectively maintained database. Univariate analysis assessed differences in 30-day outcomes after stage 1 of 2 as compared with stage 2 of 3. Data are frequency (proportion) or median. Over 5-years, 243 patients underwent HALS restorative proctocolectomy: TPC-IPAA (n= 212, 88%) or CP-IPAA (n= 30, 12%). At time of IPAA, patients in these two groups were not significantly different with respect to age, gender, BMI, medical comorbidities, and ASA classification. Two cases in TPC-IPAA had concurrent cancer, while none in the CP-IPAA did (p= 0.47). TPC-IPAA patients were less likely to have had prior abdominal (21% vs. 100%, p<0.0001) or intestinal surgery (1.4% vs. 100%, p<0.0001) compared to CP-IPAA. In regards to colitis medications, TPC-IPAA were more likely to be receiving 5-ASA (59% vs. 17%, p<0.0001), corticosteroids (75% vs. 23%, P<0.0001) or Immunomodulators (37% vs. 3.3%, p<0.0001); 13% of the TPCIPAA group, and none of the CP-IPAA group were receiving biologic therapy (p= 0.0006). In terms of severity of disease, according to the Montreal classification, TPC-IPAA had more severe disease than CP-IPAA (p<0.0001), while 23% and 13% were recently hospitalized (p= 0.2), 8% and 10% were recently transfused (p= 0.7), 12.8% and 30% were malnourished (p= 0.02), and 78.8% and 6.7% were had recently received either corticosteroids or biologic therapy (p<0.0001). In terms of surgical outcomes, 16 (7.5%) of TPC-IPAA were converted to laparotomy (most commonly for obesity, n= 4). Intra-operative complications occurred in TPC-IPAA was 8 (3.8%, most commonly for bleeding, n= 7), and after CP-IPAA none (0%, p= 0.14). TPC-IPAA had longer operative times (291 vs. 187, p<0.0001), and similar lengths of stay (5 vs. 5 days, p= 0.83) and readmissions (15.5% vs. 16.7%, p= 0.87). A total of 8% had re-operation after TPC-IPAA, and none after CP-IPAA (p= 0.03). Overall complications of any grade occurred in similar proportions (38% and 43%, p= 0.58). There were a total of 6 (2.8%) anastomotic leaks after TPC-IPAA, and none after CP-IPAA (p= 0.2). There were no mortalities in either group. Ileal pouch-anal anastomosis at the time of completion proctectomy, as compared with total proctocolectomy, is associated with shorter operative times, fewer intra-operative complications and reoperations, with similar rates of readmissions and overall complications. Further study in a larger cohort is needed to determine if a 3-stage approach to IPAA is associated with a lower anastomotic leak rate - the most important determinant of long-term pouch function and patient quality of life.

Proximal Diversion at the Time of Ileal Pouch-Anal Anastomosis for Ulcerative Colitis

Pelvic sepsis is a serious complication after ileal pouch-anal anastomosis for ulcerative colitis that may lead to pouch failure or poor function. Although a temporary loop ileostomy may be created at the time of ileal pouch-anal anastomosis to prevent or minimize the consequences of an anastomotic leak, research has suggested that an ileostomy can be safely omitted in selected patients. The purpose of this study was to examine the use of proximal diversion by colorectal surgeons at the time of ileal pouch-anal anastomosis for ulcerative colitis. A questionnaire was mailed to all practicing fellows of The American Society of Colon and Rectal Surgeons in North America. Surgeons were asked to describe their typical practice for a number of clinical scenarios. Questionnaires were mailed to 913 American Society of Colon and Rectal Surgeons fellows, and 63 percent responded. For a patient who has had a prior colectomy and is not taking steroids, 27 percent of surgeons would perform ileal pouch-anal anastomosis alone, and 73 percent would perform ileal pouch-anal anastomosis with a loop ileostomy. For a patient who has not had previous surgery and is taking prednisone 40 mg/day, 16 percent of surgeons would perform a subtotal colectomy with an end ileostomy, 82 percent would perform a total proctocolectomy and ileal pouch-anal anastomosis with a loop ileostomy, and 2 percent would perform a total proctocolectomy and ileal pouch-anal anastomosis without an ileostomy. There was no relationship between practice setting, annual ileal pouch-anal anastomosis volume, or years in practice and surgeon response for either scenario. The majority of surgeons create a temporary loop ileostomy at the time of ileal pouch-anal anastomosis for ulcerative colitis.

Age‐related analysis of functional outcome and quality of life after restorative proctocolectomy and ileal pouch‐anal anastomosis for familial adenomatous polyposis1

The aim of the present study was to evaluate the influence of a younger age at the time of ileal pouch-anal anastomosis (IPAA) on functional outcome and quality of life in patients with familial adenomatous polyposis (FAP). A total of 105 patients with FAP who had undergone IPAA were retrieved from a dedicated Institutional Review Board (IRB)-approved IPAA database. Fifty-three patients who had complete follow-up data at 1, 3 and 5 years were included in the study. Patients were categorized into three groups according to their ages at the time of surgery. Group 1, patients < or =20 years of age (n = 9); group 2, patients >20 and < or = 40 years of age (n = 23); and group 3, patients >40 years of age (n = 21). Perioperative characteristics, postoperative complications, quality of life scores and functional outcome at 1, 3 and 5 years of postoperative follow-up were assessed. At any time point, there were no significant differences among the groups in terms of perioperative characteristics, quality of life scores or level of satisfaction with the procedure. However, younger patients had significantly lower nocturnal bowel movements at the first and third years of follow-up and tended to have less bowel movements per day at all stages of follow-up. These findings indicate that younger patients with FAP are inclined to have better functional outcome after IPAA in the early postoperative period. This finding may be encouraging for colorectal surgeons who will operate on young patients with FAP.

Does smoking influence the risk of pouchitis following ileal pouch anal anastomosis for ulcerative colitis?

Objective. According to epidemiological studies, smoking habit is strongly associated with inflammatory bowel disease. Non-smokers, and especially recent ex-smokers, have an increased risk of ulcerative colitis (UC). Conversely, concerning Crohn's disease, the risk is increased among smokers. Pouchitis is the major long-term complication of restorative proctocolectomy for UC, and seems to be pathogenetically related to this condition. The aims of this study were to test the hypothesis that smoking reduces the risk of pouchitis, and to investigate whether cessation of smoking precedes the onset of the inflammation. Material and methods. All living patients operated on for UC with proctocolectomy and ileal pouch anal anastomosis (IPAA) between November 1982 and November 1996 at Sahlgren's University Hospital were included in the study (n=410). Data concerning smoking habits and pouchitis were obtained from questionnaires and from medical records. The correlation between smoking habits and incidence of pouchitis was statistically evaluated by means of a survival test and a multivariate analysis, i.e. a Poisson model. Results. In all, 327 patients (80%) completed the questionnaires. Ninety-six (29%) of these patients had had at least one episode of pouchitis. Smoking habits during follow-up did not significantly influence the risk of pouchitis (p=0.29). Nor did smoking habits before and at the time of IPAA correlate with the incidence of pouchitis. Women had a decreased risk of pouchitis, compared to men (p=0.014). There was a non-significant tendency for smoking to increase the risk, which was more pronounced in women. Conclusions. Smoking does not decrease the risk of pouchitis following IPAA for UC, and in this respect the pathogenetic model of pouchitis, suggested to be a manifestation of UC, is not supported.