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.

Causes and outcomes of pouch excision after restorative proctocolectomy.

BACKGROUND: Pouch failure occurs in up to 10 per cent of patients after ileal pouch-anal anastomosis (IPAA). The aims of this study were to determine the reasons for pouch excision and to evaluate the outcome of the perineal wound after pouch excision. METHODS: Between 1984 and 2002, 91 patients with severe ileal pouch dysfunction were treated. This was a retrospective analysis of data collected prospectively from 24 patients who underwent pouch excision. RESULTS: Patients were grouped according to the final histological diagnosis. Fourteen patients with Crohn's disease developed extensive fistulous disease and/or recurrent abscesses, of whom six had a persistent perineal sinus after pouch excision. Five patients had familial adenomatous polyposis, in three of whom desmoid tumours were the cause of failure. Three patients had chronic ulcerative colitis and developed recurrent pelvic sepsis. Finally, two patients with multiple colorectal adenocarcinoma developed recurrent cancer (one) or sepsis (one). CONCLUSION: Sepsis was the principal reason for pouch excision and was usually associated with recrudescent Crohn's disease in the pouch. Perineal wound healing was problematic after pouch excision for Crohn's disease.

Salvage reoperation for complications after ileal pouch-anal anastomosis.

BACKGROUND: Surgical revision may be possible in patients with a poor outcome following ileal pouch-anal anastomosis (IPAA), using either a transanal approach or a combined abdominoperineal approach with pouch revision and reanastomosis. METHODS: Sixty-four patients underwent revisional surgery. The indication for salvage was sepsis in 47 patients, mechanical dysfunction in ten, isolated complications of the residual glandular epithelial cuff in three and previous intraoperative difficulties in four patients. RESULTS: A transanal approach was used in 19 patients and a combined abdominoperineal procedure in 45. Six of the latter had pouch enlargement and 25 received a new pouch. During a mean(s.d.) follow-up of 30(25) months, three patients required pouch excision because of Crohn's disease. Two patients had poor continence after abdominoperineal surgery. At last follow-up 60 (94 per cent) of 64 patients had a functional pouch. Half of the patients experienced some degree of daytime and night-time incontinence, but it was frequent in only 15 per cent. Of 58 patients analysed, 27 of 40 who had an abdominoperineal procedure and 13 of 18 who had transanal surgery rated their satisfaction with the outcome as good to excellent. CONCLUSION: Surgical revision after failure of IPAA was possible in most patients, yielding an acceptable level of bowel function in two-thirds of patients.

Desmoid tumors in familial adenomatous polyposis: a pilot project evaluating efficacy of treatment with pirfenidone.

OBJECTIVES: Pirfenidone (Deskar, Marnac Inc., Dallas, TX), 5-methyl-1-phenyl-2-(1H)-pyridone, is a broad-spectrum, noncytotoxic, oral antifibrotic agent that is reported to inhibit or block the action of cytokine growth factors: transforming growth factor beta1, platelet-derived growth factor, epidermal growth factor, and fibroblast growth factor, and to prevent formation of new fibrotic lesions. METHODS: We enrolled 10 women and four men with extensive familial adenomatous polyposis (FAP)-associated desmoid disease in a 2-yr open-label treatment trial with oral pirfenidone. Imaging of desmoids was conducted at baseline and 6, 12, and 24 months. RESULTS: No drug toxicity or drug intolerance was encountered. Seven patients dropped out (three because of progressive disease), and seven continued for at least 18 months. Of those that continued, two had partial but significant reduction in the size of all desmoids beginning in the first 6 months of treatment, and two others experienced relief of symptoms without change in desmoid size. Three patients experienced no change in tumor size or symptoms. CONCLUSIONS: Pirfenidone is well tolerated by patients with FAP-associated desmoid tumors. Some patients with FAP/desmoid tumors treated with pirfenidone had regression of tumors, some had progression, and some had no response. Patients with rapidly growing tumors did not respond to pirfenidone. A placebo-controlled trial is needed to determine whether there is a subset of patients for whom pirfenidone may result in partial shrinkage of desmoid tumors, because the natural history of desmoid tumors is not predictable or understood.

Anal canal strictures after ileal pouch-anal anastomosis.

PURPOSE: This study was designed to define the different types of strictures, the factors favoring their occurrence, and their treatment after ileal pouch-anal anastomosis. METHODS: Between January 1981 and June 1996, 1,884 ileal pouch-anal anastomoses were constructed at the Mayo Clinic in Rochester, Minnesota. Data were collected prospectively and included age, gender, type of underlying diseases (chronic ulcerative colitis familial adenomatous polyposis), proctologic antecedents, technique of anastomosis, intraoperative difficulties, and postsurgical complications. Strictures were categorized as nonfibrotic and fibrotic on the basis of the presence or absence of a fibrotic segment at the anal canal anastomosis that was responsible for pouch-outlet obstruction requiring at least one dilation. RESULTS: Strictures occurred in 213 patients (11.2 percent; 11 percent for chronic ulcerative colitis and 12 percent for familial adenomatous polyposis; P = not significant). Strictures were nonfibrotic in 86.4 percent of patients and fibrotic in 13.6 percent. A greater number of strictures were observed after a handsewn anastomosis (12 percent) than after a stapled anastomosis (4 percent; P = 0.03). Intraoperative technical difficulties were associated with 13 percent of all strictures regardless of the type of stricture (fibrotic, 7.5 percent; nonfibrotic, 14 percent; P = 0.4). Postoperative complications such as abscess, fistula, and pouch retraction were found in 13 percent of cases and were primarily associated with fibrotic strictures. Treatment included dilation, which was successful in 95 percent of nonfibrotic strictures but in only 45 percent of fibrotic strictures (P = 0.0001). Surgical treatment was required in 25 strictures (12 percent), including excision of the strictured segment with mucosal advancement flap (5 patients), excision of the pouch with permanent ileostomy (9 patients), or redo pouch (3 patients). With one exception, all excised pouches were associated with other perianastomotic complications, such as abscess, fistula, and pouch retraction. The remaining eight patients had other surgical procedures because of abscess (n = 3), division of an obstructive bridge (n = 2), and débridement and curettage of a fistula (n = 3) with dilation for associated strictures. CONCLUSIONS: Strictures were observed in 11.2 percent of the patients in this study. Nonfibrotic strictures responded well to anal dilation, whereas fibrotic strictures were more commonly associated with intraoperative or postoperative complications, often necessitated surgical therapy to salvage pouch function, and were eventually responsible for pouch failure in nine patients.

Locally recurrent rectal cancer.

Local recurrence (LR) varies from less than 4% to greater than 50%; several tumor factors and operative techniques may influence rate of LR. Of greatest interest has been the considerable inter-surgeon variation, even within the same institution. An LR rate of less than 10% has been consistently reported by those who use total mesorectal excision even without any form of adjuvant therapy, either preoperatively or postoperatively. These findings raise important questions about surgical technique, subspecialty teaching, place of adjuvant therapy and quality assurance. The management of LR by a multispecialty team and multimodality treatment including preoperative chemoradiation, surgical resection and intraoperative radiotherapy provides encouraging results in terms of better local control and prolonged survivorship in carefully selected patients. These uncontrolled results justify further evaluation of these salvage operations in a more controlled manner that should include repercussions on the quality of life of the patients.

Bleeding from cavernous angiomatosis of the rectum in Klippel-Trenaunay syndrome: report of three cases and literature review.

Klippel-Trenaunay syndrome (KTS) is a congenital vascular anomaly characterized by limb hypertrophy, cutaneous hemangiomas, and varicosities. GI hemorrhage is a potentially serious complication secondary to diffuse hemangiomatous involvement of the gut. We report on three patients with KTS who presented with transfusion-dependent anemia and life-threatening bleeding due to extensive cavernous hemangiomas involving the rectum. Two patients were treated by proctocolectomy and coloanal anastomosis, which preserved anal function while controlling bleeding. The third patient required an abdominoperineal resection because of extensive rectal, perianal, and perineal angiomatosis. The literature on the evaluation and management of GI hemorrhage in KTS, particularly of colorectal origin, is reviewed.

Intraoperative irradiation for locally recurrent colorectal cancer in previously irradiated patients.

PURPOSE: Information in the literature regarding salvage treatment for patients with locally recurrent colorectal cancer who have previously been treated with high or moderate dose external beam irradiation (EBRT) is scarce. A retrospective review was therefore performed in our institution to determine disease control, survival, and tolerance in patients treated aggressively with surgical resection and intraoperative electron irradiation (IOERT) +/- additional EBRT and chemotherapy. METHODS AND MATERIALS: From 1981 through 1994, 51 previously irradiated patients with recurrent locally advanced colorectal cancer without evidence of distant metastatic disease were treated at Mayo Clinic Rochester with surgical resection and IOERT +/- additional EBRT. An attempt was made to achieve a gross total resection before IOERT if it could be safely accomplished. The median IOERT dose was 20 Gy (range, 10--30 Gy). Thirty-seven patients received additional EBRT either pre- or postoperatively with doses ranging from 5 to 50.4 Gy (median 25.2 Gy). Twenty patients received 5-fluorouracil +/- leucovorin during EBRT. Three patients received additional cycles of 5-fluorouracil +/- leucovorin as maintenance chemotherapy. RESULTS: Thirty males and 21 females with a median age of 55 years (range 31--73 years) were treated. Thirty-four patients have died; the median follow-up in surviving patients is 21 months. The median, 2-yr, and 5-yr actuarial overall survivals are 23 months, 48% and 12%, respectively. The 2-yr actuarial central control (within IOERT field) is 72%. Local control at 2 years has been maintained in 60% of patients. There is a trend toward improved local control in patients who received > or =30 Gy EBRT in addition to IOERT as compared to those who received no EBRT or <30 Gy with 2-yr local control rates of 81% vs. 54%. Distant metastatic disease has developed in 25 patients, and the actuarial rate of distant progression at 2 and 4 years is 56% and 76%, respectively. Peripheral neuropathy was the main IOERT-related toxicity; 16 (32%) patients developed neuropathies (7 mild, 5 moderate, 4 severe). Ureteral narrowing or obstruction occurred in seven patients. All but one patient with neuropathy or ureter fibrosis received IOERT doses > or =20 Gy. CONCLUSION: Long-term local control can be obtained in a substantial proportion of patients with aggressive combined modality therapy, but long-term survival is poor due to the high rate of distant metastasis. Re-irradiation with EBRT in addition to IOERT appears to improve local control. Strategies to improve survival in these poor-risk patients may include the more routine use of conventional systemic chemotherapy or the addition of novel systemic therapies.

Characteristics and evolution of extraintestinal manifestations associated with ulcerative colitis after proctocolectomy.

AIMS: Describe the characteristics of extraintestinal manifestations complicating ulcerative colitis present preoperatively and determine their evolution after surgery. METHODS: Between 1976 and 1986, 281 patients with ulcerative colitis exhibiting one or more extraintestinal manifestations (EIM) before either IPAA (n = 147), Brooke ileostomy (n = 71), Kock pouch (n = 48) or ileorectostomy (n = 15) were assessed retrospectively. The clinical evolution of each manifestation was classified as having disappeared, improved, remained unchanged or aggravated postoperatively. An efficacy index was designed to assess the ratio of the number of cases cured or improved over the number of cases unchanged or aggravated. The relationship between EIM and gender, age, duration of disease and the type of surgery was also ascertained. RESULTS: 433 EIM were observed in 281 patients. The most common were arthralgias of the large joints (n = 146), of the sacroiliac joint (n = 59) and the small joints (n = 51). In comparison to patients without EIM having received the same operation during the same period of time, EIM were seen more often in women, younger patients, than those with longer duration of disease and the ileoanal anastomosis group. 60% had only one EIM at a time. Based on the efficacy index, thromboembolic accidents and erythema nodosum were the most commonly cured or improved. Ocular manifestations and primary sclerosing cholangitis were unaffected. The other EIM responded favorably but variably with improvement in two thirds of patients. The presence of a rectal remnant (IRA) or ileal reservoir did not affect the evolution of the EIM. CONCLUSIONS: Thromboembolic complications which are life-threatening, erythema nodosum and arthralgia of the small and large joints which impair quality of life, benefited the most from proctocolectomy. Those conditions may be considered preoperatively when making the decision for surgery.

Does technique of anastomosis play any role in developing late perianal abscess or fistula?

PURPOSE: This study examines the risk factors for developing perianal abscess or fistula formation after ileal pouch-anal anastomosis procedure for chronic ulcerative colitis or familial adenomatous polyposis. METHODS: A total of 1,457 patients with J-pouch, 1,304 (89.5 percent) with chronic ulcerative colitis and 153 (10.5 percent) with familial adenomatous polyposis who had a two-stage procedure without any evidence of previous perianal disease were included in the study. The effect of pouch-to-anal anastomosis type on perianal abscess or fistula formation was evaluated. RESULTS: A total of 108 patients (7.4 percent) had a perianal abscess or fistula after the ileal pouch-anal anastomosis procedure after at least one year of follow-up. No statistically significant difference was identified in fistula formation regarding the age and gender of the patients (P > 0.05), nor did the risk of fistula formation differ significantly between the patients with handsewn vs. stapled anastomoses (P > 0.05). However, patients with a diagnosis of chronic ulcerative colitis, compared with patients with familial adenomatous polyposis, had a statistically higher risk of developing abscess or fistula (P = 0.012). CONCLUSION: The most important risk factor in developing perianal sepsis in long-term patients with ileal pouch-anal anastomosis is the initial disease type. After excluding patients without Crohn's disease, the risk of developing an abscess or fistula was found to be significantly greater in patients with chronic ulcerative colitis compared with patients with familial adenomatous polyposis, and this risk is independent of anastomotic technique.

Familial adenomatous polyposis: results after ileal pouch-anal anastomosis in teenagers.

PURPOSE: Virtually all untreated patients with familial adenomatous polyposis develop colorectal carcinoma. Thus, prophylactic colectomy is indicated. Detractors of ileal pouch-anal anastomosis prefer ileorectal anastomosis for teenagers because of the potential negative impact of ileal pouch-anal anastomosis on quality of life. The aim of this study was to assess the effects on quality of life of ileal pouch-anal anastomosis in teenagers with familial adenomatous polyposis. METHODS: Between 1981 and 1998, 48 teenagers underwent ileal pouch-anal anastomosis for familial adenomatous polyposis. One patient had proctectomy and ileal pouch-anal anastomosis after previous ileorectal anastomosis. A temporary diverting loop ileostomy was established in 42 patients (87.5 percent). One patient had colonic carcinoma diagnosed preoperatively. Two other patients were found to have unsuspected rectal cancer at surgery. Mean follow-up (+/- standard deviation) in 43 patients was 80.5 +/- 42 months. RESULTS: There was no immediate postoperative mortality. Postoperative complications included pelvic sepsis (3 patients; 1 requiring reoperation) and bleeding (1 patient; no surgery required). One patient died of metastatic colonic carcinoma. Ten patients required reoperation, seven had bowel obstruction, one had portal hypertension, and two required an ileostomy. The mean (+/- standard deviation) daytime and nighttime stool frequency was 4 +/- 1.5 and 1 +/- 1, respectively. One patient reported daytime and nighttime incontinence, and two patients reported nighttime incontinence only. No patient experienced impotence or retrograde ejaculation. Social, sexual, sport, housework, recreation, family, travel, and work activities were improved or unchanged in 82.5, 87, 80, 90, 80, 92.5, 77.5, and 89 percent of patients, respectively. Three male patients fathered children, and three female patients had a total of six children after normal pregnancies and deliveries. CONCLUSION: The impact of ileal pouch-anal anastomosis on quality of life was favorable in the majority of teenagers. The risk of rectal cancer should be the major consideration before proposing an operation to teenagers with familial adenomatous polyposis.

Functional outcomes after ileal pouch-anal anastomosis for chronic ulcerative colitis.

OBJECTIVE: To assess long-term outcomes after ileal pouch-anal anastomosis (IPAA) for chronic ulcerative colitis (CUC) with specific emphasis on patient sex, childbirth, and age. SUMMARY BACKGROUND DATA: Childbirth and the process of aging affect pelvic floor and anal sphincter function independently. Early function after IPAA is good for most patients. Nonetheless, there are concerns about the impact of the aging process as well as pregnancy on long-term functional outcomes after IPAA. METHODS: Functional outcomes using a standardized questionnaire were prospectively assessed for each patient on an annual basis. RESULTS: Of the 1,454 patients who underwent IPAA for CUC between 1981 and 1994, 1,386 were part of this study. Median age was 32 years. Median length of follow-up was 8 years. Pelvic sepsis was the primary cause of pouch failure irrespective of sex or age. Functional outcomes were comparable between men and women. Eighty-five women who became pregnant after IPAA had pouch function, which was comparable with women who did not have a child. Daytime and nocturnal incontinence affected older patients more frequently than younger ones. Incontinence became more common the longer the follow-up in older patients, but this was not found in younger patients. Poor anal function led to pouch excision in only 3 of 204 older patients. CONCLUSIONS: Incontinence rates were significantly higher in older patients after IPAA for CUC compared with younger patients. However, this did not contribute to a greater risk of pouch failure in these older patients. Patient sex and uncomplicated childbirth did not affect long-term functional outcomes.

Care of patients and their families with familial adenomatous polyposis.

Familial adenomatous polyposis (FAP) is a dominantly inherited disorder that is typically characterized by the appearance of multiple colorectal adenomas usually by the teenage years, with a risk of early colorectal cancer approaching 100%. Genetic testing can help determine which family members have the disorder and require surveillance endoscopy. Astute physicians may detect unsuspected FAP in patients with extraintestinal manifestations such as hard or soft cutaneous tumors. Colectomy will prevent cancer but is often necessary before the patient is 20 years old. Postoperative lifelong surveillance is indicated to screen for associated duodenal, thyroid, and rectal or ileal neoplasms. Attenuated FAP variants are less typical and may be confused with other types of familial colorectal neoplasia. Chemoprevention, regression, and other treatment strategies are being developed to improve the management of extracolonic neoplasms and desmoid tumors. A better understanding of the natural history of these FAP-associated phenomena will facilitate the rational selection of interventions. Management guidelines that were recently developed at Mayo Clinic Rochester to provide for uniform care and surveillance are discussed.

Long-term functional results of radiation after coloanal anastomosis

Surgery is the only treatment that can cure most patients with colorectal cancer. Radiation therapy (pre or postoperative) has been shown to improve results by decreasing local recurrence and improving survival. Our aim was to analyze whether postoperative radiation influenced long-term functional outcomes and the probability of stricture of anastomosis in patients who underwent coloanal anastomosis for rectal cancer. Methods: The records of 84 patients with coloanal anastomosis for rectal cancer were studied between 1980 and 1996. There were 82 males and 28 females. Mean age was 57.8 years (range 24 to 78 years). Mean distal resection margin was 2.6 cm (range 0 to 14cm). Twenty-three patients received postoperative irradiation therapy. Patients who received chemotherapy were not included in the study. Results were analysed by examination , telephone or questionnaire. Mean follow-up was 3.8 years (range 0 to 13 years). Results: There was no operative mortality. Functional variables were much better in non-irradiated patients. The irradiated group had more number of stools/day (p>0.05), more number of stools/ night (p>0.05), more incontinence/day (p<0.05) and more incontinence/night (p<0.05). Irradiated patients also wore more pads (p<0.05) than non-irradiated patients. The probability of remaining free of stricture at 5 years was slightly better in non-irradiated (72 percent) than in irradiated patients (65 percent, p>0.05). Conclusion: Postoperative irradiation after colo-anal anastomosis for rectal cancer is safe, but may increase the risk of stricture of anastomosis and does affect functional results adversely

Basal cell carcinoma of the perianal region: 20-year experience.

INTRODUCTION: Although basal cell carcinoma remains the most common cutaneous malignancy, its occurrence in the perianal region is very rare. Earlier reports have suggested that basal cell carcinoma in this region may be more aggressive than basal cell carcinoma in other regions of the body. METHODS: A chart review of patients with perianal basal cell carcinoma who presented consecutively during a 20-year period (ending December 1996) was performed. Patients included were those with a histologically proven diagnosis of basal cell carcinoma in the perianal region. RESULTS: Twenty-one cases were identified (15 male) with a mean age at diagnosis of 67 (range, 43-81) years. Follow-up data were available on 19 patients with a mean follow-up time of 72 (range, 2-214) months. Seventeen patients were treated by local excision, one by electrocautery, and one by Moh's surgery. No patients developed a local recurrence. Seven patients (33 percent) had multiple basal cell carcinomas at other anatomic sites. Four patients died of other causes during the follow-up period. CONCLUSIONS: Perianal basal cell carcinoma is a rare tumor. Given the significant association with multiple lesions at other sites, a diagnosis of perianal basal cell carcinoma should prompt an examination of all cutaneous surfaces. It does not seem to be more aggressive in this region than in other areas. Local excision seems to provide adequate control.

Misdiagnosis of specific cytomegalovirus infection of the ileoanal pouch as refractory idiopathic chronic pouchitis: report of two cases.

PURPOSE: Chronic nonspecific reservoir ileitis (pouchitis) occurs in 5 to 10 percent of patients who undergo ileal pouch-anal anastomosis for ulcerative colitis. Specific infection of the ileal pouch-anal anastomosis with cytomegalovirus has not been reported. AIM: We report two patients with specific cytomegalovirus infection of the ileal pouch-anal anastomosis, initially misdiagnosed as idiopathic chronic pouchitis. CASE SERIES: Patient 1 had ileal pouch-anal anastomosis for ulcerative colitis. Three years later she had diarrhea, fever, pelvic pain, and pouch inflammation at endoscopy consistent with pouchitis. She had no response to medical therapy. Repeat endoscopy showed persistent inflammation and biopsies showed cytomegalovirus. She had symptomatic improvement after treatment with intravenous ganciclovir, 10 mg/kg/day for ten days (stopped for rash). Repeat pouch biopsies were negative for cytomegalovirus. Patient 2 had ileal pouch-anal anastomosis for ulcerative colitis. Nine years later she had resection of obstructing stricture at previous loop ileostomy site. She underwent reoperation with ileostomy and pouch defunctionalization for peritonitis. Four weeks later she had fever and bloody discharge from the diverted pouch. Pouch endoscopy with biopsy showed inflammation consistent with pouchitis. She had no response to medical therapy. Re-examination of pouch biopsies with a specific monoclonal immunofluorescent stain showed cytomegalovirus. She had symptomatic improvement after treatment with intravenous ganciclovir, 10 mg/kg/day for 21 days. Repeat pouch biopsies were negative for cytomegalovirus. CONCLUSIONS: Specific cytomegalovirus infection of the ileal pouch-anal anastomosis may be misdiagnosed as idiopathic refractory chronic pouchitis. Cytomegalovirus must be excluded before immune modifier therapy or pouch excision in these patients.

Management of desmoid tumors in patients after ileal pouch-anal anastomosis for familial adenomatous polyposis.

PURPOSE: The aim of this study was to review the management of desmoid tumors in patients who have undergone ileal pouch-anal anastomosis for familial adenomatous polyposis and their outcome. METHODS: A retrospective review of case notes was undertaken in a series of 196 patients with familial adenomatous polyposis who had had an ileal pouch-anal anastomosis. Eleven patients were identified in whom desmoid tumor had developed (4 male; median age, 30 (range, 16-43) years). RESULTS: Desmoid tumors developed in the abdominal wall alone in 4 of 11 patients. Three enlarging tumors were resected with no subsequent recurrence. No patient received adjuvant treatment and pouch function remained stable at a median follow-up of eight years. Mesenteric desmoid tumors developed in seven patients; the pouch has been excised in two because of ischemia; two other patients have had defunctioning stomas created because of slow progression of their desmoid tumors. One patient had a single-lumen pouch excised and a new S-pouch inserted, with no subsequent recurrence of the desmoid tumor, and in two patients the mesenteric desmoid tumor has remained unchanged. All of these patients received long-term Clinoril (sulindac, Merck & Co., Inc., West Point, PA). Although there has been no significant deterioration in pouch function in patients in whom the pouch remains in situ, the pouch function was significantly worse compared with a control group of patients after ileal pouch-anal anastomosis for familial adenomatous polyposis in whom desmoid tumors did not develop. CONCLUSION: Desmoid tumors developed in 5.6 percent of 196 patients after ileal pouch-anal anastomosis for familial adenomatous polyposis. No patient with abdominal-wall desmoid tumor had a recurrence after local excision. By contrast, mesenteric desmoid tumors eventually resulted in pouch failure in four of seven affected patients.

Incidence and subsequent impact of pelvic abscess after ileal pouch-anal anastomosis for chronic ulcerative colitis.

PURPOSE: This study was designed to measure the impact of pelvic abscess on eventual pouch failure and functional outcome after ileal pouch-anal anastomosis in patients with chronic ulcerative colitis. PATIENTS AND METHODS: The outcome of 1,508 patients who underwent ileal pouch-anal anastomosis for chronic ulcerative colitis at the Mayo Clinic was determined from a central patient registry, data were collected prospectively. RESULTS: Seventy-three patients developed a pelvic abscess as a complication of ileal pouch-anal anastomosis. Pouch failure occurred in 19 (26 percent). Forty-eight patients (55 percent) required transabdominal salvage surgery, 6 (8 percent) underwent local surgery, and the remaining 27 (37 percent) were treated nonsurgically. Wound infection was more common in patients who experienced pelvic abscess. The majority of pouch failures secondary to pelvic abscess formation occurred within two years of ileal pouch-anal anastomosis. Daytime incontinence, the use of a protective pad, and the need for constipating or bulking medication were significantly more common among patients who had an abscess but kept their reservoir. Ability to perform work and domestic activities and to undertake recreational activities were significantly more restricted among these patients. CONCLUSIONS: Pouch failure occurs in one-fourth of patients who retain their pouch despite pelvic abscess after ileal pouch-anal anasto mosis. Among patients who retain their pouch despite postoperative pelvic abscess, functional outcome and quality of life are significantly poorer than in patients in whom no sepsis occurred.

J ileal pouch-anal anastomosis for chronic ulcerative colitis: complications and long-term outcome in 1310 patients.

AIM: The purpose of the study was to determine the risk of postoperative complications and the functional outcome after a hand-sewn ileal pouch-anal anastomosis (IPAA) for ulcerative colitis using a single J-shaped pouch design. METHODS: Preoperative function, operative morbidity and long-term functional outcome were assessed prospectively in 1310 patients who underwent IPAA between 1981 and 1994 for ulcerative colitis. RESULTS: Three patients died after operation. Postoperative pelvic sepsis rates decreased from 7 per cent in 1981-1985 to 3 per cent in 1991-1994 (P = 0.02). After mean follow-up of 6.5 (range 2-15) years, the mean number of stools was 5 per day and 1 per night. Frequent daytime and nighttime incontinence occurred in 7 and 12 per cent of patients respectively, and did not change over a 10-year period. The cumulative probability of suffering at least one episode of 'clinical' pouchitis was 18 and 48 per cent at 1 and 10 years and the cumulative probability of pouch failure at 1 and 10 years was 2 and 9 per cent respectively. CONCLUSION: These results indicate that increased experience decreases the risk of pouch-related complications and that with time the functional results remain stable, but the failure rate increases.