Pouchitis After Ileal Pouch-Anal Anastomosis: A Pouchitis Disease Activity Index

A safe and practical procedure for total colectomy and mucosal proctectomy with ileonal anastomosis has been developed and performed by us on 11 patients with adenomatosis coli and two patients with ulcerative colitis. The major features of the operative procedure are 1) total removal of the rectal mucosa to just above the dentate line; 2) preservation of anorectal function by a long rectal cuff procedure achieved by rectal mucosal excision from a level just below the sacral promontory, using a rectal internal stent and gauze packing techniques for rectal mucosal stripping, with, in some patients, an ileal reservoir added; and 3) prevention of pelvic sepsis by intraoperative rectal irrigation, rectal cuff drainage, and a temporary defunctioning loop ileostomy. Of six patients with at least three months of follow-up after reconstruction, each has returned to normal life, averaging two to seven semiformed stools each day. A side-to-end ileoanal anastomosis with a lowlying, loop-type ileal reservoir provided the best functional results.

Total colectomy, mucosal proctectomy, and ileoanal anastomosis

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 night-time 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. © 1998 British Journal of Surgery Society Ltd

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

Background:Ileal pouch anal anastomosis (IPAA) is the treatment of choice for chronic, medically refractory mucosal ulcerative colitis, indeterminate colitis, familial adenomatous polyposis (FAP), and a select group of patients with Crohn's disease.Aim:We report outcomes, complications, and quality

Ileal pouch anal anastomosis: analysis of outcome and quality of life in 3707 patients.

Objective To evaluate prospectively long-term quality of life and functional outcome after restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis, and to evaluate and validate a novel quality-of-life indicator in this group of patients. Background Data Restorative proctocolectomy with ileal pouch-anal anastomosis is now the preferred option when total proctocolectomy is required for ulcerative colitis or familial adenomatous polyposis, but long-term data on functional outcome and quality of life after the procedure are lacking. Methods Patients (n = 977) who underwent RPC with stapled anastomosis for colitis or polyposis coli and who were followed for ≥12 months were included. Quality of life, fecal incontinence, and satisfaction with surgery were prospectively evaluated by structured interview or questionnaire for 1 to 12 years after surgery (median 5.0). Quality of life was scored using the Cleveland Global Quality of Life (CGQL) instrument (Fazio Score). This is a novel score developed over the past 15 years by the senior author. Quality of life was also evaluated in a subgroup of patients with the Short Form 36 (SF-36). The CGQL was validated by determining its reliability, responsiveness, and validity as well as its correlation with the SF-36 score. Results Postoperative quality of life as measured by SF-36 was excellent and compared well with published norms for the general U.S. population. The CGQL was found to be reliable, responsive, and valid, and there was a high correlation with the SF-36 scores. Using the CGQL, quality of life was shown to increase after the first 2 years after surgery, and there was no deterioration thereafter. The prevalence of perfect continence increased from 75.5% before surgery to 82.4% after surgery, and although this deteriorated somewhat >2 years after surgery, it was no worse than preoperative values. Ninety-eight percent of patients would recommend the surgery to others. Conclusions Long-term quality of life after ileal pouch surgery is excellent and the level of continence is satisfactory. This surgery is an excellent long-term option in patients requiring total proctocolectomy. The CGQL is a simple, valid, and reliable measure of quality of life after pelvic pouch surgery and may well be applicable in many other clinical conditions.

Long-term functional outcome and quality of life after stapled restorative proctocolectomy.

An operation has been developed that permits total removal of all disease-prone mucosa in ulcerative colitis but avoids the need for a permanent ileostomy. The colon and upper half of the rectum are excised and the remaining inflamed mucosa is stripped from the rectal stump down to the dentate line of the anal canal. A pouch is fashioned from a triplicated loop of terminal ileum. This is drawn down through the denuded rectum and an anastomosis created, via the per-anal approach, between the ileum just distal to the pouch and the mid-anal canal. A temporary ileostomy is made. Out of eight patients so treated, five were available for assessment, and four of them were highly satisfied with the result in improved health and function. The remaining three were awaiting closure of their ileostomies.

https://www.bmj.com/content/bmj/2/6130/85.full.pdf

A G Parks

Papers

Proctocolectomy without ileostomy for ulcerative colitis.