Pouch excision: indications and outcomes.

AIM: Restorative proctocolectomy with ileal-pouch anal anastomosis is the procedure of choice for ulcerative colitis. Unfortunately, up to 10% of pouches will fail, requiring either reconstruction or excision. While several series have reported on the aetiology of pouch failure, no study to date has focused on the postoperative complications associated with pouch excision. METHODS: Patients who had excision of ileoanal reservoir with ileostomy (CPT code 45136) were included. Data abstracted included preoperative, operative and postoperative variables. A Kaplan-Meier curve of pouch survival was performed. RESULTS: In all, 147 patients met the inclusion criteria for the study. The median age of patients was 47 years (73 women), and 132 had a diagnosis of ulcerative colitis at the time of colectomy. The most common indications for pouch excision were sepsis (n = 46; 31%) and Crohn's disease (n = 37; 25%). 84 (57%) patients experienced short-term (< 30 days) postoperative complications, the most common of which was a surgical site infection (n = 32; 21%); 55 (37%) patients had long-term complications (> 30 days) postoperatively, the most common of which was a return to the operating room (n = 19; 13%) largely for perineal wounds. Thirty-day mortality was zero. 4.8%, 47.6%, 65.3% and 84.4% of patients had undergone pouch excision by 1, 5, 10 and 20 years from the time of pouch construction, respectively. CONCLUSIONS: Pouch excision has a high rate of both short- and long-term postoperative complications. Patients should be appropriately counselled to set expectations accordingly. In view of these findings we suggest that this operation should ideally be performed at a high volume centre with the availability of a multidisciplinary surgical team.

Safety, feasibility, and short-term outcomes in 588 patients undergoing minimally invasive ileal pouch-anal anastomosis: a single-institution experience.

PURPOSE: A laparoscopic approach to proctocolectomy and ileal pouch-anal anastomosis (IPAA) in patients with chronic ulcerative colitis and familial adenomatous polyposis has grown in popularity secondary to reports of small series demonstrating short-term patient benefits. Limited data exist in large numbers of patients undergoing laparoscopic ileal pouch-anal anastomosis (L-IPAA). We aimed to analyze surgical outcomes in a large cohort of patients undergoing L-IPAA. METHODS: From a prospectively maintained surgical database, 30-day surgical outcome data were reviewed for all L-IPAA performed for chronic ulcerative colitis and familial adenomatous polyposis from 1999 to 2012. Demographics, operative approach, and operative and postoperative complications were analyzed. RESULTS: A total of 588 L-IPAA ileal pouch-anal anastomoses were performed predominantly for chronic ulcerative colitis (93.9 %). The mean age was 36.2 years, and 54.3 % were male, with a mean BMI of 24.1 kg/m(2). Three-stage operations were performed in 17.7 %. The mean operating time of the patients excluding 3-stage operation was 269.4 min. Minimally invasive techniques included hand-assist in 55 % and straight laparoscopy in 45 %. Conversion to open occurred in 8.8 %. Median length of stay was 5 days. There was no mortality. Complications occurred in 36.9 % of patients: Clavien grade I (17.5 %), grade II (72.8 %), and grade III (9.7 %). Analysis of the grouped data over time demonstrated a statistically significant reduction in operative time (p < 0.001) and an increase in the ratio of hand-assisted over straight laparoscopy (p = 0.001). CONCLUSIONS: Minimally invasive IPAA performed using either a laparoscopic or hand-assisted technique is safe, can be performed with low conversion rates, and confers beneficial perioperative outcomes.

What is the likelihood of colorectal cancer when surgery for ulcerative-colitis-associated dysplasia is deferred?

AIM: Surgery aims to prevent cancer-related morbidity for patients with ulcerative colitis (UC) associated dysplasia. The literature varies widely regarding the likelihood of dysplastic progression to higher grades of dysplasia or cancer. The aim of this study was to characterize the likelihood of the development of colorectal cancer (CRC) of patients with UC-associated dysplasia who chose to defer surgery. METHOD: A retrospective review was carried out of patients undergoing surgery for UC at the Mayo Clinic, who were diagnosed to have dysplasia between August 1993 and July 2012. The relationships between grade of dysplasia, time to surgery and the detection of unsuspected carcinoma were investigated. RESULTS: In all, 175 patients underwent surgery at a median of 4.9 (interquartile range 2.5-8.9) months after a diagnosis of dysplasia. Their median age was 52 (interquartile range 43-59) years. An initial diagnosis of indeterminate dysplasia was not associated with CRC [0/23; 17.7 (8.1-29.6) months]. Thirty-six patients who had an initial diagnosis of dysplasia progressed from indeterminate to low-grade dysplasia [24.2 (11.0-30.4) months]. Low-grade dysplasia was associated with a 2% (1/56; T2N0M0) risk of CRC when present in random surveillance biopsies and a 3% (2/61; T1N0M0, T4N0M0) risk if detected in endoscopically visible lesions [7.4 (5.2-33.3) months]. Eighteen patients progressed from indeterminate to high-grade dysplasia [19.1 (9.2-133.9) months]. Seventeen patients progressed from low to high-grade dysplasia [11.0 (5.8-30.1) months]. None of the patients with high-grade dysplasia (0/35) progressed to CRC [4.5 (1.7-9.9) months]. CONCLUSION: Dysplasia was associated with a low incidence of node negative CRC if surgery was deferred for up to 5 years. These findings may help inform the decision-making process for asymptomatic patients who are having to decide between intensive surveillance or surgery for UC-associated dysplasia.

Systematic review with meta-analysis: faecal diversion for management of perianal Crohn's disease.

BACKGROUND: Temporary faecal diversion is sometimes used for management of refractory perianal Crohn's disease (CD) with variable success. AIMS: To perform a systematic review with meta-analysis to evaluate the effectiveness, long-term outcomes and factors associated with success of temporary faecal diversion for perianal CD. METHODS: Through a systematic literature review through 15 July 2015, we identified 16 cohort studies (556 patients) reporting outcomes after temporary faecal diversion. We estimated pooled rates [with 95% confidence interval (CI)] of early clinical response, attempted and successful restoration of bowel continuity after temporary faecal diversion (without symptomatic relapse), and rates of re-diversion (in patients with attempted restoration) and proctectomy (with or without colectomy and end-ileostomy). We identified factors associated with successful restoration of bowel continuity. RESULTS: On meta-analysis, 63.8% (95% CI: 54.1-72.5) of patients had early clinical response after faecal diversion for refractory perianal CD. Restoration of bowel continuity was attempted in 34.5% (95% CI: 27.0-42.8) of patients, and was successful in only 16.6% (95% CI: 11.8-22.9). Of those in whom restoration was attempted, 26.5% (95% CI: 14.1-44.2) required re-diversion because of severe relapse. Overall, 41.6% (95% CI: 32.6-51.2) of patients required proctectomy after failure of temporary faecal diversion. There was no difference in the successful restoration of bowel continuity after temporary faecal diversion in the pre-biological or biological era (13.7% vs. 17.6%, P = 0.60), in part due to selection bias. Absence of rectal involvement was the most consistent factor associated with restoration of bowel continuity. CONCLUSIONS: Temporary faecal diversion may improve symptoms in approximately two-thirds of patients with refractory perianal Crohn's disease, but bowel restoration is successful in only 17% of patients.

Outcomes after implementation of a multimodal standard care pathway for laparoscopic colorectal surgery.

BACKGROUND: The aim of the study was to assess which aspects of an enhanced recovery programme are associated with better outcomes following laparoscopic colorectal surgery. METHODS: A database of laparoscopic colorectal procedures performed in 2011 was reviewed. Elements of the enhanced recovery programme and compliance were evaluated for short-term (30-day) outcomes. Individual elements included gabapentin, celecoxib, intrathecal analgesia, diet, postoperative fluids, and paracetamol/non-steroidal anti-inflammatory drug pain management. RESULTS: Five hundred and forty-one consecutive procedures were included. Compliance with the enhanced recovery programme elements ranged from 82.4 to 99.3 per cent. Median length of hospital stay was 3 (i.q.r. 2-5) days, with 25.9 per cent of patients discharged within 48 h. Patients without complications had a median length of stay of 3 (i.q.r. 2-4) days if compliant and 3 (3-5) days if not (P < 0.001). Low oral opiate intake (oral morphine equivalent of less than 30 mg) (odds ratio (OR) 1.97, 95 per cent confidence interval 1.29 to 3.03; P = 0.002), full compliance (OR 2.36, 1.42 to 3.90; P < 0.001) and high surgeon volume (more than 100 cases per year) (OR 1.50, 1.19 to 1.89; P < 0.001) were associated with discharge within 48 h. Compliance with the elements of oral intake and fluid management in the first 48 h was associated with a reduced rate of complications (8.1 versus 19.6 per cent; P = 0.001). Median oral opiate intake was 37.5 (i.q.r. 0-105) mg in 48 h, with 26.2 per cent of patients receiving no opiates. CONCLUSION: Compliance with an enhanced recovery pathway was associated with less opiate use, fewer complications and a shorter hospital stay.

Intraoperative, postoperative and reoperative problems with ileoanal pouches.

BACKGROUND: Proctocolectomy with ileal pouch-anal anastomosis (IPAA) has been developed and refined since its introduction in the late 1970s. Nonetheless, it is a procedure associated with significant morbidity. The aim of this review was to provide a structured approach to the challenges that surgeons and physicians encounter in the management of intraoperative, postoperative and reoperative problems associated with ileoanal pouches. METHODS: The review was based on relevant studies identified from an electronic search of MEDLINE, Embase and PubMed databases from 1975 to April 2011. There were no language or publication year restrictions. Original references in published articles were reviewed. RESULTS: Although the majority of patients experience long-term success with an ileoanal pouch, significant morbidity surrounds IPAA. Surgical intervention is often critical to achieve optimal control of the situation. CONCLUSION: A structured management plan will minimize the adverse consequences of the problems associated with pouches.

Outcomes following surgery without radiotherapy for rectal cancer.

BACKGROUND: This study determined survival and recurrence rates following curative resection of rectal cancer without radiotherapy. METHODS: This was a retrospective review of the Mayo Clinic database of patients with rectal cancer treated with curative intent using surgery alone from 1990 to 2006. Patients who received neoadjuvant chemotherapy or radiation therapy and those who had any postoperative radiotherapy were excluded. Details were collected from the database and patient records using a protocol approved by the institutional review board. RESULTS: Some 655 consecutive patients with rectal cancer treated with curative intent using surgery alone were identified; 397 had stage I disease, 125 stage II and 133 stage III. Four hundred and nine patients underwent anterior resection (AR) and 246 abdominoperineal resection (APR). Median follow-up was 62 months. The 5-year rate of local recurrence was 4·3 per cent, disease-free survival 90·0 per cent and cancer-specific survival 91·5 per cent. Stage-specific and all-stage disease-free survival did not differ significantly between AR and APR. The 5-year cumulative local recurrence rate was lower following AR than APR (3·6 versus 5·5 per cent; P = 0·321). There were only two patients with positive margins and type of operation was not significant on multivariable analysis. CONCLUSION: Well-performed, standardized APRs have similar local recurrence to AR. Radiation therapy may not confer much additional benefit.

Laparoscopic surgery for rectal cancer: short-term benefits and oncologic outcomes using more than one technique.

BACKGROUND: Several minimally invasive techniques have now been described for rectal cancer resection. Current outcome data for these approaches from high volume, single institutions remain limited. Our aim was to review outcomes in patients undergoing minimally invasive surgery for rectal cancer at our institution in the current era. METHODS: A retrospective analysis was done to assess short-term benefits and oncologic outcomes in patients undergoing minimally invasive surgery for rectal cancer between 2004 and 2007. RESULTS: One-hundred consecutive patients (61 men, median age 62) with a median follow-up of 1.8 years were identified. Sixty-seven had hand-assisted laparoscopic surgery (HALS), while 33 were done laparoscopic-assisted (LA). Seventy-two patients underwent anterior resection, 27 an abdominal perineal resection, and 1 a total proctocolectomy. Tumor stage was stage 1 (21%), stage 2 (17%), stage 3 (56%), and stage 4 (6%). A median of 16 lymph nodes, a median 3.4 cm distal margin, and a 99% negative circumferential margin was achieved. The 3-year disease-free and overall survivals were 86.2 and 94.5%, respectively. Three cases required conversion. Median time to both diet and first bowel movement was 3 days, and median length of stay was 5 days. Length of stay, time to soft diet, incision length, and pain scores were less using a LA approach compared to HALS (P < 0.01). Overall morbidity was 26% with no mortality. CONCLUSION: Both minimally invasive techniques used achieved excellent oncologic results in patients with rectal cancer. The LA approach had slightly better short-term outcomes.

Ileal pouch-anal anastomosis and liver transplantation for ulcerative colitis complicated by primary sclerosing cholangitis.

BACKGROUND: The aim was to evaluate outcomes in patients with ulcerative colitis complicated by primary sclerosing cholangitis (PSC) who required ileal pouch-anal anastomosis (IPAA) and orthotopic liver transplantation (OLT). METHODS: A retrospective analysis was performed of 32 patients undergoing both IPAA and OLT between 1980 and 2006. Data were collected regarding demographics, indication for surgery, postoperative complications, and outcome of IPAA and OLT. RESULTS: Thirty-day mortality after either procedure was nil. The median preoperative Model for End-stage Liver Disease (MELD) score for the group with initial IPAA was 8 (range 6-20) and the postoperative score was 11 (range 6-19). At 1 and 10 years, 32 and 26 of the 32 liver grafts had survived, and 31 and 30 of the 32 pouches, respectively. Fourteen patients require daily medical therapy for chronic pouchitis. At a median follow-up of 3.6 (range 0.2-16.2) years after the second of two procedures, responding patients reported a median of 5.5 stools per day and 2 stools per night. CONCLUSION: IPAA and OLT are feasible and safe in patients requiring both procedures for ulcerative colitis and PSC. Functional outcomes are stable over time, despite an increased risk of chronic pouchitis.

Results at up to 20 years after ileal pouch-anal anastomosis for chronic ulcerative colitis.

BACKGROUND: Ileal pouch-anal anastomosis (IPAA) is performed routinely for chronic ulcerative colitis. METHODS: Using data from a prospective database and annual standardized questionnaires, functional outcome, complications and quality of life (QoL) after IPAA were assessed. RESULTS: Some 1885 IPAA operations were performed for chronic ulcerative colitis over a 20-year period (mean follow-up 11 years). The mean age at the time of IPAA was 34.1 years, increasing from 31.2 years (1981-1985) to 36.3 years (1996-2000). The overall rate of pouch success at 5, 10, 15 and 20 years was 96.3, 93.3, 92.4 and 92.1 per cent respectively. Mean daytime stool frequency increased from 5.7 at 1 year to 6.4 at 20 years (P < 0.001), and also increased at night (from 1.5 to 2.0; P < 0.001). The incidence of frequent daytime faecal incontinence increased from 5 to 11 per cent during the day (P < 0.001) and from 12 to 21 per cent at night (P < 0.001). QoL remained unchanged and 92 per cent remained in the same employment. Seventy-six patients were eventually diagnosed with indeterminate colitis and 47 with Crohn's disease. CONCLUSION: IPAA is a reliable surgical procedure for patients requiring proctocolectomy for chronic ulcerative colitis and indeterminate colitis. The clinical and functional outcomes are excellent and stable for 20 years after operation.

Sphincter-preserving radiation therapy for rectal cancer: a simulation study using three-dimensional computerized technology.

BACKGROUND: The acquisition of detailed computerized tomography (CT) imaging at the time of simulation, along with three-dimensional (3D) treatment planning software has been integrated with radiation delivery hardware to create the modality known as 3D conformal radiotherapy (3DXRT). This approach provides, in theory, a means to selectively subtract the anal sphincter from the high-dose field of irradiation in patients with stage II and III adenocarcinomas of the mid-rectum scheduled for low anterior resection (LAR). HYPOTHESIS: Implementation of 3DXRT with sphincter blocking may be a feasible strategy to reduce the dose of radiation distributed to the anal canal without reduction in the dose distribution to the gross tumour volume (GTV) plus adequate margins. METHODS: Pretreatment simulation CT scans of 10 patients with rectal cancers located between 5 and 10 cm from the anal verge were retrieved from a computerized database. Radiation oncologists and colorectal surgeons defined the contours of the GTV and the anal sphincter, respectively, on successive CT scan slices. These contours provided the volumetric data required to quantify dose distribution and compute dose-volume histograms. The standard mode of pelvic irradiation planned with CT simulation was compared with a 'virtual CT simulation' approach, in which a sphincter block was added to the protocol. RESULTS: The mean distance of tumours from the anal verge was 6.3 cm. In the virtual simulation treatment plan, a 2-cm margin separated the sphincter block from the lower limit of the GTV. The mean volume of the anal sphincter was 16.1 +/- 3.5 cm(3). The dose distributed to the GTV in the real plan and in the virtual simulated block plan were 51.7 +/- 1.4 and 51.6 +/- 1.4 Gy respectively (P = 0.85). By comparison the mean dose distributed to the anal sphincter was dramatically reduced by using a sphincter block (33.2 +/- 12 Gy vs 6.4 +/- 4.1 Gy, P < 0.001). CONCLUSION: During a course of radiotherapy for most low- or mid-rectal cancers, the anal canal is included within the field of irradiation with a mean dose distribution to the sphincter of 33 Gy. Evaluation of 3DXRT with full sphincter block (mid-rectum) and partial sphincter block (distal rectum) is a feasible strategy to decrease the volume of anal sphincter carried to full dose without reduction in dose to the GTV. This approach, by minimizing treatment-induced damage to the anal sphincter, might improve functional outcome of LAR.

Diagnosis and treatment of perianal fistulas in Crohn disease.

Perianal fistulas occur in up to 43% of patients with Crohn disease. Diagnostic evaluation to determine the location and type of fistulas and the presence or absence of rectal inflammation is required. A combined medical and surgical approach to the management of such patients is the optimal treatment plan. Perianal abscesses must be drained. Superficial, low transsphincteric, and low intersphincteric fistulas are usually treated with fistulotomy and antibiotics. High transsphincteric, suprasphincteric, and extrasphincteric fistulas are usually treated with noncutting setons, antibiotics, and azathioprine or 6-mercaptopurine and, in many cases, infliximab.

A comparison of endoscopic ultrasound, magnetic resonance imaging, and exam under anesthesia for evaluation of Crohn's perianal fistulas.

BACKGROUND & AIMS: To determine accuracy of endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI) for evaluation of Crohn's disease perianal fistulas. METHODS: Thirty-four patients with suspected Crohn's disease perianal fistulas were prospectively enrolled in a blinded study comparing EUS, MRI, and examination under anesthesia (EUA). Fistulas were classified according to Parks' criteria, and a consensus gold standard was determined for each patient. Acceptable accuracy was defined as agreement with the consensus gold standard for > or =85% of patients. RESULTS: Three patients did not undergo MRI; 1 did not undergo EUS or EUA; and consensus could not be reached for 1. Thirty-two patients had 39 fistulas (20 trans-sphincteric, 5 extra-sphincteric, 6 recto-vaginal, 8 others) and 13 abscesses. The accuracy of all 3 modalities was > or =85%: EUS 29 of 32 (91%, confidence interval [CI] 75%-98%), MRI 26 of 30 (87%, CI 69%-96%), and EUA 29 of 32 (91%, CI 75%-98%). Accuracy was 100% when any 2 tests were combined. CONCLUSIONS: EUS, MRI, and EUA are accurate tests for determining fistula anatomy in patients with perianal Crohn's disease. The optimal approach may be combining any 2 of the 3 methods.

Rectal compliance, capacity, and rectoanal sensation in fecal incontinence.

OBJECTIVE: Assessments of the pathophysiology of fecal incontinence are skewed toward anal sphincter function; however, rectal compliance, rectoanal sensation and capacity may also be relevant. The aim of this study was to evaluate the usual and some novel diagnostic approaches in fecal incontinence. METHODS: In 22 unselected patients with fecal incontinence (21 F, 33-75 yr), we quantified: 1) symptoms, anorectal manometry, and anal ultrasound; 2) anal perception of temperature and light touch; 3) rectal sensitivity and compliance to distension; and 4) rectal reservoir function. Control values were obtained from two groups of 11 (seven F, 32-53 yr), and 32 (18 F, 19-44 yr) volunteers. RESULTS: Patients had urge (14), passive (four), or combined (four) fecal incontinence; symptoms were mild in three, moderate in nine, and severe in 10 patients. Most had low sphincteric pressures and ultrasonic abnormalities. Temperature perception was impaired (p < 0.05) in incontinent patients, to a greater extent in the proximal anal canal and in patients with passive, as opposed to urge, incontinence. Intraluminal pressures for sensations of rectal distension were lower in incontinent patients (p = 0.02). Artificial stools elicited sensations of rectal filling at lower volumes than did a barostat bag, and in patients with urge, as opposed to passive, incontinence. In patients and controls, the sensation of urgency was associated (r2 = 0.2, p < 0.01) with rectal compliance. CONCLUSIONS: We confirm that temperature sensation is impaired, and perception of rectal distension is not always reduced in fecal incontinence. Artificial stool tended to induce sensations at lower volumes than did balloon inflation. Altered sensory mechanisms may contribute to the pathophysiology of fecal incontinence.

Pouch and pouchitis.

Pouchitis is an inflammation of unknown origin occurring in the ileal pouch after IPAA. It is considered by many to be a form of ulcerative colitis that recurs in the pouch and rarely, if ever, occurs in patients with FAP. Most patients respond to a short course of antibiotics. When remission cannot be maintained or the disease is nonresponsive to prolonged treatment with antibiotics, anti-inflammatory agents or steroids may be useful. A variety of alternative drugs have been tried with mixed success and should be considered as experimental. Rarely, when pouchitis is refractory to medical management, excision of the pouch may be required.

American Gastroenterological Association Medical Position Statement: guidelines on constipation.

This document presents the official recommendations of the American Gastroenterological Association (AGA) on constipation. It was approved by the Clinical Practice and Practice Economics Committee on March 4, 2000, and by the AGA Governing Board on May 21, 2000.

AGA technical review on constipation. American Gastroenterological Association.

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. The paper was approved by the Committee on March 4, 2000, and by the AGA Governing Board on May 21, 2000.

Ileal pouch-anal anastomosis in patients with indeterminate colitis: long-term results.

PURPOSE: Patients with chronic ulcerative colitis who undergo proctocolectomy and are found intraoperatively to harbor histologic signs suggesting Crohn's disease have indeterminate colitis; nonetheless, ileal pouch-anal anastomosis is usually performed. The aim of this study was to determine the long-term outcome of ileal pouch-anal anastomosis in patients with indeterminate colitis compared with a cohort of patients with chronic ulcerative colitis. METHOD: Review of an ileal pouch-anal anastomosis registry identified 1,437 patients with chronic ulcerative colitis and 82 patients with indeterminate colitis who underwent an ileal pouch-anal anastomosis between 1981 and 1995. The median follow-up was 83 (range, 1-192) months. Demographic data and functional outcomes were compared by chi-squared and Wilcoxon's rank-sum tests. Probabilities of complications and pouch failure were analyzed using Kaplan-Meier and log-rank techniques. Finally, Bonferroni adjustments were used for multiple comparisons. RESULTS: Patients with indeterminate colitis and chronic ulcerative colitis were comparable in terms of gender and length of follow-up. The mean age of the chronic ulcerative colitis group was higher (34 vs. 31; P < 0.01). At ten years patients with indeterminate colitis had significantly more episodes of pelvic sepsis (17 percent indeterminate colitis vs. 7 percent chronic ulcerative colitis; P < 0.001), pouch fistula (31 vs. 9 percent; P < 0.001), and pouch failure (27 vs. 11 percent; P < 0.001). Importantly, during follow-up fully 15 percent of patients with indeterminate colitis, but only 2 percent of patients with chronic ulcerative colitis, had their original diagnosis changed to Crohn's disease (P < 0.001). When the outcomes of these patients newly diagnosed with Crohn's disease were considered separately, the rate of complications for the remaining patients with indeterminate colitis was identical to that of patients with chronic ulcerative colitis. Functional outcomes were comparable among all three groups. CONCLUSION: After ileal pouch-anal anastomosis patients with indeterminate colitis who did not develop Crohn's disease subsequently experienced long-term outcomes nearly identical to patients with chronic ulcerative colitis. Crohn's disease, whether it develops after surgery for chronic ulcerative colitis or indeterminate colitis, is associated with poor long-term outcomes.