Comparable perioperative outcomes, long-term outcomes, and quality of life in a retrospective analysis of ulcerative colitis patients following 2-stage versus 3-stage proctocolectomy with ileal pouch-anal anastomosis.

PURPOSE: Many surgeons assume 3-stage ileal pouch-anal anastomosis (IPAA) is safer than 2-stage IPAA in patients with active ulcerative colitis (UC), although recent data suggest outcomes are comparable. This study aimed to compare perioperative complications, late complications, and functional outcomes after 2- versus 3-stage IPAA in patients with active UC. METHODS: A retrospective review was conducted of patients who underwent 2- or 3-stage IPAA for active UC from 2000 to 2015 in a high-volume institution. Patients completed quality-of-life surveys 6 months following ileostomy reversal. Perioperative and late complications were recorded. Outcomes were compared with the Fisher exact test, and multivariable logistic regression was used to adjust for potential confounders. RESULTS: We identified 212 patients who underwent 2- or 3-stage IPAA for active UC, of whom 157 patients (74.1%) underwent 2-stage procedures and 55 (25.9%) underwent 3-stage procedures. More patients undergoing 2-stage procedures were taking immunomodulators preoperatively (46.3% vs. 23.1%, p = 0.01), but there was no difference in use of steroids (p = 0.09) or biologic agents (p = 0.85). Three-stage procedures were more likely to be urgent (78.6% vs. 30.2%, p < 0.001). There were no differences in perioperative complications (p = 0.50), anastomotic leak (p = 0.94), pouchitis (p = 0.45), pouch failure (p = 0.46), perceived quality of life (p = 0.68), number of bowel movements per day (p = 0.27), or sexual satisfaction (p = 0.21) between the 2- and 3-stage groups. CONCLUSIONS: Patients undergoing 2-stage compared to 3-stage IPAA for active ulcerative colitis have comparable outcomes and quality of life following ileostomy reversal. Two-stage IPAA appears to be safe and appropriate, even in high-risk patients.

Impact of Rising Grades of Internal Rectal Intussusception on Fecal Continence and Symptoms of Constipation.

BACKGROUND: A theory of rectal intussusception has been advanced that intrarectal intussusception, intra-anal intussusception, and external rectal prolapse are points on a continuum and are a cause of fecal incontinence and constipation. OBJECTIVE: This study evaluates the association among rectal intussusception, constipation, fecal incontinence, and anorectal manometry. DESIGN: Patients undergoing defecography were studied from a prospectively maintained database and classified according to the Oxford Rectal Prolapse Grade as normal or having intra-rectal, intra-anal, or external intussusception. Patient symptoms were assessed using the Constipation Severity Index and the Fecal Incontinence Severity Index. Quality-of-life surveys were also used. Patients also underwent anorectal manometry. SETTINGS: The study was conducted at a tertiary care university medical center (Massachusetts General Hospital). PATIENTS: The study included 147 consecutive patients undergoing evaluation for evacuatory dysfunction and involved defecography, symptoms questionnaires, and anorectal physiology testing from January 2011 to December 2013. MAIN OUTCOME MEASURES: Symptom severity and quality-of-life scores were measured, as well as anal manometry results. RESULTS: Increasing Oxford grade was associated with an increase in severity of fecal incontinence (median score: normal = 23.9, intrarectal = 21.0, intra-anal = 30.0, external prolapse = 35.3; ß = 4.71; p = 0.009), which persisted in a multivariable model including age (ß = 2.13; p = 0.03), and decreased sphincter pressures (median mean resting pressure: normal = 75.4, intra-rectal = 69.7, intra-anal = 64.3, external prolapse = 48.3; ß = -8.57; p = 0.003), which did not persist in a multivariable model. Constipation severity did not increase with rising intussusception (mean score: normal = 37.4, intrarectal = 35.0, intra-anal = 41.4, external prolapse = 32.9; p = 0.79), and balloon expulsion improved rather than worsened (normal = 47.1%, intrarectal = 60.5%, intra-anal = 82.9%, external prolapse = 93.1%; p < 0.001). LIMITATIONS: The study was limited because it was an observational study from a single center. CONCLUSIONS: Increasing grades of rectal intussusception are associated with increasing fecal incontinence but not constipation.

Effect of Coexisting Pelvic Floor Disorders on Fecal Incontinence Quality of Life Scores: A Prospective, Survey-Based Study.

BACKGROUND: The association between an objective measure of fecal incontinence severity and patient-reported quality of life is poorly understood. OBJECTIVE: The purpose of this study was to evaluate patients with various degrees of fecal incontinence to determine whether their quality of life as measured by the Fecal Incontinence Quality of Life Scale is affected by coexisting pelvic floor disorders. DESIGN: This was a prospective, survey-based study. SETTINGS: The study was conducted at a tertiary pelvic floor disorders center. PATIENTS: Included patients were all of those presenting between January 2007 and March 2014. MAIN OUTCOME MEASURES: Survey data were analyzed to determine the association between Fecal Incontinence Severity Index and Fecal Incontinence Quality of Life Scale, as well as scores from the Constipation Severity Instrument, Pelvic Floor Impact Questionnaire, Pelvic Organ Distress Inventory, and Urinary Distress Inventory. RESULTS: A total of 585 patients reported fecal incontinence ranging from none (n = 191) to mild/moderate (n = 159) to severe (n = 235). As expected, patients with severe fecal incontinence have worse scores on all fecal incontinence quality-of-life subscales (lifestyle, coping/behavior, depression/self-perception, and embarrassment) and worse colorectal/anal symptoms than those with mild/moderate or no fecal incontinence (p < 0.0001). Patients with severe fecal incontinence also have worse bladder/urinary symptoms (p ≤ 0.0001). Pelvic organ prolapse and constipation symptoms were similar between groups (p ≥ 0.61). After correcting for baseline differences in patient comorbidities and bladder/urinary symptoms, a significant association persisted between Fecal Incontinence Severity Index and all of the subscales of the fecal incontinence quality-of-life instrument (p < 0.0001). However, urinary distress scores also remained significantly associated with all of the fecal incontinence quality-of-life subscales except for embarrassment after risk adjustment (p < 0.01). LIMITATIONS: Nongeneral population and a lack of patient data on previous medical management of fecal incontinence were limitations of this study. CONCLUSIONS: The Fecal Incontinence Quality of Life Scale correlates strongly with instruments measuring both fecal and urinary incontinence. This underscores the importance of quantifying the presence or absence of coexistent urinary leakage in studies where a drop in fecal incontinence quality of life is considered a primary end point.

Noninvasive echocardiographic estimation of pulmonary wedge pressure in candidates for and recipients of heart transplantation.

OBJECTIVE: We assessed the value of deceleration time (dt) of diastolic wave of pulmonary venous flow (PVF) (PVF_dt) as noninvasive estimation of pulmonary wedge pressure (PWP) in candidates for and recipients of heart transplantation. METHODS: We prospectively recruited 51 patients with end-stage congestive heart failure (group A) and 49 recipients of heart transplantation (group B). PWP and PVF_dt were measured using a Swan-Ganz catheter and Doppler echocardiography, respectively. We performed regression analyses to assess interrelationships. Moreover, we used the area under the receiver operating characteristic curve to assess how clearly PVF_dt could discriminate between normal and elevated PWP values. RESULTS: In both study groups, PWP was inversely associated with PVF_dt (R(2) = 0.785 and 0.797, respectively, P < .001). A cut-off value of less than 187 milliseconds was predictive of an elevated PWP value (> or =12 mm Hg) in both study groups. Specificity and sensitivity were between 90% and 100%, respectively, in both study groups. The area under the receiver operating characteristic curve was 0.961 (0.908-1.013; P < .001) for group A and 0.998 (0.992-1.04; P < .001) for group B. CONCLUSION: In recipients of heart transplantation and patients with end-stage congestive heart failure, the noninvasive measuring of PVF_dt distinguishes between normal and elevated PWP values.

Magnetic resonance low-dose dobutamine test is superior to SCAR quantification for the prediction of functional recovery.

BACKGROUND: Low-dose dobutamine challenge (DSMR) by MRI was compared with delayed enhancement imaging with Gd-DTPA (SCAR) as a predictor of improvement of wall motion after revascularization (RECOVERY). METHODS AND RESULTS: In 29 patients with coronary artery disease (68+/-7 years of age, 2 women, 32+/-8% ejection fraction), wall motion was evaluated semiquantitatively by MRI before and 3 months after revascularization. SCAR and DSMR were performed before revascularization. The transmural extent of scar was assessed semiquantitatively. Binary prediction of RECOVERY was performed by logistic regression in 288 segments with wall motion abnormalities at rest. Receiver operating characteristic-area under curve (AUC) statistics were used to compare different models. Low-dose DSMR (AUC 0.838) was superior to SCAR (AUC 0.728) in predicting RECOVERY. SCAR did not improve accuracy of prediction by DSMR. Subgroup analysis showed superiority of DSMR for 1% to 74% transmural extent of infarction. CONCLUSIONS: Low-dose DSMR is superior to SCAR in predicting RECOVERY. This advantage is largest in segments with a delayed enhancement of 1% to 74%.