PURPOSE: This study was designed to determine the outcome of patients with Crohn’ s disease and indeterminate colitis who have an ileal pouch- anal anastomosis. METHODS: Between 1982 and 2001, 1,270 patients underwen...PURPOSE: This study was designed to determine the outcome of patients with Crohn’ s disease and indeterminate colitis who have an ileal pouch- anal anastomosis. METHODS: Between 1982 and 2001, 1,270 patients underwent a restorative proctocolectomy at the Mount Sinai Hospital: 1,135 had ulcerative colitis, 36 had Crohn’ s disease, 21 had indeterminate colitis, and 78 had another diagnosis. Perioperative data were collected prospectively. Functional outcomes were assessed with a 35- question survey mailed to all patients with a functioning pouch of at least six months duration. RESULTS: Pouch complications were significantly more common in patients with Crohn’ s disease (64 percent) and indeterminate colitis (43 percent) compared with patients with ulcerative colitis (22 percent) (P < 0.05). Similarly, 56 percent of patients with Crohn’ s disease had their pouch excised or defunctioned, compared with 10 percent of patients with indeterminate colitis and 6 percent with ulcerative colitis (P < 0.01). In the subgroup of patients with a diagnosis of Crohn’ s disease, multivariate analysis revealed that the pathologist’ s initial designation of ulcerative colitis (based on the colectomy specimen) and an increasing number of pathologic, clinical, and endoscopic features of Crohn’ s disease were independently associated with pouch failure. The functional results in patients with Crohn’ s disease with a successful pouch were not significantly different from those with indeterminate colitis or ulcerative colitis. CONCLUSIONS: Although complication rates may be higher in patients with indeterminate colitis compared with ulcerative colitis, the overall pouch failure rate is similar. On the other hand, more than one- half of patients with Crohn’ s disease will require pouch excision or diversion. Our data suggest that it is difficult to identify patients with Crohn’ s disease who are likely to have a successful outcome after restorative proctocolectomy. Thus, Crohn’ s disease should remain a relative contraindication to restorative proctocolectomy, whereas ileal pouch- anal anastomosis is an acceptable alternative for patients with indeterminate colitis.展开更多
Proctocolectomy modifies the enterohepatic circulation and activity of bacteri al enzymes depending on the structure of the stoma and function of the terminal ileum. We evaluated in our comparative study effects of di...Proctocolectomy modifies the enterohepatic circulation and activity of bacteri al enzymes depending on the structure of the stoma and function of the terminal ileum. We evaluated in our comparative study effects of different colectomy cons tructions on cholesterol metabolism. Levels of lipoprotein cholesterol and trigl ycerides, noncholesterol sterols, and squalene in serum, fecal fat, and bile aci ds, cholesterol absorption efficiency, and cholesterol metabolism by sterol bala nce technique were analyzed in human subjects with ileal pouch-anal anastomosis (n=34), conventional ileostomy (n =8), ileorectostomy (n =6), and controls (n = 29). Malabsorption of bile acids, but not of fat, and low serum levels of total and low-density lipoprotein cholesterol, but high levels of high-density lipop rotein cholesterol and increased cholesterol synthesis were evident in the colec tomy groups. In contrast to the ileorectostomy group, expressing high absorption and biliary secretion of cholesterol, a low cholesterol absorption percentage a ccompanied by elevated serum proportions of cholesterol precursor sterols and ph ytosterols characterized the ileal pouch-anal anastomosis and conventional ileo stomy groups. After colectomy, fecal excretion of secondary bile acids was low, wher eas relative proportions of identifiable bile acids remained the same in each st udy group. Low serum levels of total and lowdensity lipoprotein cholesterol of c olectomized subjects may decrease the risk of premature atherosclerosis. The fav orable serum lipid profile was due to enhanced fecal loss of cholesterol as bile acids despite abnormally high cholesterol synthesis. Ileal dysfunction probably diminished cholesterol absorption in subjects with ileal pouch-anal anastomosi s and conventional ileostomy, with no explanation for those with ileorectostomy with no clinical gastrointestinal dysfunction. Relative synthesis of identifiabl e primary bile acids remained unchanged postoperatively, but formation of second ary bile acids was weak due to scarce bacterial flora.展开更多
PURPOSE: This study was designed to evaluate the impact of childbirth on anal sphincter integrity and function, functional outcome, and quality of life in females with restorative proctocolectomy and ileal pouch- anal...PURPOSE: This study was designed to evaluate the impact of childbirth on anal sphincter integrity and function, functional outcome, and quality of life in females with restorative proctocolectomy and ileal pouch- anal anastomosis. METHODS: The patients who had at least one live birth after ileal pouch- anal anastomosis were asked to return for a comprehensive assessment. They were asked to complete the following questionnaires: the Short Form- 36, Cleveland Global Quality of Life scale, American Society of Colorectal Surgeons fecal incontinence severity index, and time trade- off method. Additionally, anal sphincter integrity (endosonography) and manometric pressures were measured by a medical physician blinded to the delivery technique. Anal sphincter physiology also was evaluated with electromyography and pudendal nerve function by nerve terminal motor latency technique. RESULTS: Of 110 eligible females who had at least one live birth after ileal pouch- anal anastomosis, 57 participated in the study by returning for clinical evaluation to the clinic and 25 others by returning the quality of life and functional outcome questionnaires. Patients were classified into two groups: patients who had only cesarean section delivery after ileal pouch- anal anastomosis (n = 62) and patients who had at least one vaginal delivery after ileal pouch- anal anastomosis (n = 20). The mean follow- up from the date of the most recent delivery was 4.9 years. The vaginal delivery group had significantly higher incidence of an anterior sphincter defect by anal endosonography (50 percent)vs. cesarean section delivery group (13 percent; P = 0.012). The mean squeeze anal pressure was significantly higher in the patients who had only cesarean section delivery (150 mmHg)after restorative proctocolectomy than patients who had at least one vaginal delivery (120 mmHg) after restorative proctocolectomy (P = 0.049). Quality of life evaluated by time trade- off method also was significantly better in the cesarean section delivery group (1) vs. vaginal delivery group (0.9; P < 0.001). CONCLUSIONS: The risk of the sphincter injury and quality of life measured by time trade- off method are significantly worse after vaginal delivery compared with cesarean section in patients with ileal pouch- anal anastomosis. In the short- term, this does not seem to substantially influence pouch function or quality of life; however, the long- term effects remain unknown, thus obstetric concern may not be the only factor dictating the type of delivery in this group of patients. A planned cesarean section may eliminate these potential and factual concerns in ileal pouch- anal anastomosis patients.展开更多
PURPOSE: Controversy exists regarding the safety for omission of diverting ileostomy in restorative proctocolectomy because of fears of increased septic complications. This study was designed to evaluate the outcomes ...PURPOSE: Controversy exists regarding the safety for omission of diverting ileostomy in restorative proctocolectomy because of fears of increased septic complications. This study was designed to evaluate the outcomes of restorative proctocolectomy in a consecutive series of patients by comparing postoperative complications, functional results, and quality of life in patients with and without diverting ileostomy. METHODS: Data regarding demograph- ics, length of stay, surgical characteristics, and complications were reviewed and recorded according to the presence (n= 1,725) or absence (n = 277) of a diverting ileostomy at the time of pelvic pouch surgery. Criteria for omission of ileostomy included: stapled anastomosis, tension-free anastomosis, intact tissue rings, good hemostasis, absence of airleaks, malnutrition, toxicity, anemia, and prolonged consumption of steroids. Functional outcome and quality of life indicators were prospectively recorded and compared. RESULTS: Patients in the ileostomy group had greater body surface area and older mean age at time of surgery, were taking greater doses of steroids preoperatively, and required more blood transfusions at the time of surgery compared with the one-stage (P < 0.05). There were no differences between the two groups in septic complications (P > 0.05). Early postoperative ileus was more common in the one-stage group (P < 0.001). There were no differences between the groups in quality of life and functional outcomes. CONCLUSIONS: For carefully selected patients undergoing restorative proctocolectomy with ileal pouch-anal anastomosis, omission of diverting ileost- omy is a safe procedure that does not lead to an increase inseptic complications or mortality. Quality of life and functional results are similar to those who undergo ileal pouch-anal anastomosis with diversion, provided that certain selection factors are considered.展开更多
文摘PURPOSE: This study was designed to determine the outcome of patients with Crohn’ s disease and indeterminate colitis who have an ileal pouch- anal anastomosis. METHODS: Between 1982 and 2001, 1,270 patients underwent a restorative proctocolectomy at the Mount Sinai Hospital: 1,135 had ulcerative colitis, 36 had Crohn’ s disease, 21 had indeterminate colitis, and 78 had another diagnosis. Perioperative data were collected prospectively. Functional outcomes were assessed with a 35- question survey mailed to all patients with a functioning pouch of at least six months duration. RESULTS: Pouch complications were significantly more common in patients with Crohn’ s disease (64 percent) and indeterminate colitis (43 percent) compared with patients with ulcerative colitis (22 percent) (P < 0.05). Similarly, 56 percent of patients with Crohn’ s disease had their pouch excised or defunctioned, compared with 10 percent of patients with indeterminate colitis and 6 percent with ulcerative colitis (P < 0.01). In the subgroup of patients with a diagnosis of Crohn’ s disease, multivariate analysis revealed that the pathologist’ s initial designation of ulcerative colitis (based on the colectomy specimen) and an increasing number of pathologic, clinical, and endoscopic features of Crohn’ s disease were independently associated with pouch failure. The functional results in patients with Crohn’ s disease with a successful pouch were not significantly different from those with indeterminate colitis or ulcerative colitis. CONCLUSIONS: Although complication rates may be higher in patients with indeterminate colitis compared with ulcerative colitis, the overall pouch failure rate is similar. On the other hand, more than one- half of patients with Crohn’ s disease will require pouch excision or diversion. Our data suggest that it is difficult to identify patients with Crohn’ s disease who are likely to have a successful outcome after restorative proctocolectomy. Thus, Crohn’ s disease should remain a relative contraindication to restorative proctocolectomy, whereas ileal pouch- anal anastomosis is an acceptable alternative for patients with indeterminate colitis.
文摘Proctocolectomy modifies the enterohepatic circulation and activity of bacteri al enzymes depending on the structure of the stoma and function of the terminal ileum. We evaluated in our comparative study effects of different colectomy cons tructions on cholesterol metabolism. Levels of lipoprotein cholesterol and trigl ycerides, noncholesterol sterols, and squalene in serum, fecal fat, and bile aci ds, cholesterol absorption efficiency, and cholesterol metabolism by sterol bala nce technique were analyzed in human subjects with ileal pouch-anal anastomosis (n=34), conventional ileostomy (n =8), ileorectostomy (n =6), and controls (n = 29). Malabsorption of bile acids, but not of fat, and low serum levels of total and low-density lipoprotein cholesterol, but high levels of high-density lipop rotein cholesterol and increased cholesterol synthesis were evident in the colec tomy groups. In contrast to the ileorectostomy group, expressing high absorption and biliary secretion of cholesterol, a low cholesterol absorption percentage a ccompanied by elevated serum proportions of cholesterol precursor sterols and ph ytosterols characterized the ileal pouch-anal anastomosis and conventional ileo stomy groups. After colectomy, fecal excretion of secondary bile acids was low, wher eas relative proportions of identifiable bile acids remained the same in each st udy group. Low serum levels of total and lowdensity lipoprotein cholesterol of c olectomized subjects may decrease the risk of premature atherosclerosis. The fav orable serum lipid profile was due to enhanced fecal loss of cholesterol as bile acids despite abnormally high cholesterol synthesis. Ileal dysfunction probably diminished cholesterol absorption in subjects with ileal pouch-anal anastomosi s and conventional ileostomy, with no explanation for those with ileorectostomy with no clinical gastrointestinal dysfunction. Relative synthesis of identifiabl e primary bile acids remained unchanged postoperatively, but formation of second ary bile acids was weak due to scarce bacterial flora.
文摘PURPOSE: This study was designed to evaluate the impact of childbirth on anal sphincter integrity and function, functional outcome, and quality of life in females with restorative proctocolectomy and ileal pouch- anal anastomosis. METHODS: The patients who had at least one live birth after ileal pouch- anal anastomosis were asked to return for a comprehensive assessment. They were asked to complete the following questionnaires: the Short Form- 36, Cleveland Global Quality of Life scale, American Society of Colorectal Surgeons fecal incontinence severity index, and time trade- off method. Additionally, anal sphincter integrity (endosonography) and manometric pressures were measured by a medical physician blinded to the delivery technique. Anal sphincter physiology also was evaluated with electromyography and pudendal nerve function by nerve terminal motor latency technique. RESULTS: Of 110 eligible females who had at least one live birth after ileal pouch- anal anastomosis, 57 participated in the study by returning for clinical evaluation to the clinic and 25 others by returning the quality of life and functional outcome questionnaires. Patients were classified into two groups: patients who had only cesarean section delivery after ileal pouch- anal anastomosis (n = 62) and patients who had at least one vaginal delivery after ileal pouch- anal anastomosis (n = 20). The mean follow- up from the date of the most recent delivery was 4.9 years. The vaginal delivery group had significantly higher incidence of an anterior sphincter defect by anal endosonography (50 percent)vs. cesarean section delivery group (13 percent; P = 0.012). The mean squeeze anal pressure was significantly higher in the patients who had only cesarean section delivery (150 mmHg)after restorative proctocolectomy than patients who had at least one vaginal delivery (120 mmHg) after restorative proctocolectomy (P = 0.049). Quality of life evaluated by time trade- off method also was significantly better in the cesarean section delivery group (1) vs. vaginal delivery group (0.9; P < 0.001). CONCLUSIONS: The risk of the sphincter injury and quality of life measured by time trade- off method are significantly worse after vaginal delivery compared with cesarean section in patients with ileal pouch- anal anastomosis. In the short- term, this does not seem to substantially influence pouch function or quality of life; however, the long- term effects remain unknown, thus obstetric concern may not be the only factor dictating the type of delivery in this group of patients. A planned cesarean section may eliminate these potential and factual concerns in ileal pouch- anal anastomosis patients.
文摘PURPOSE: Controversy exists regarding the safety for omission of diverting ileostomy in restorative proctocolectomy because of fears of increased septic complications. This study was designed to evaluate the outcomes of restorative proctocolectomy in a consecutive series of patients by comparing postoperative complications, functional results, and quality of life in patients with and without diverting ileostomy. METHODS: Data regarding demograph- ics, length of stay, surgical characteristics, and complications were reviewed and recorded according to the presence (n= 1,725) or absence (n = 277) of a diverting ileostomy at the time of pelvic pouch surgery. Criteria for omission of ileostomy included: stapled anastomosis, tension-free anastomosis, intact tissue rings, good hemostasis, absence of airleaks, malnutrition, toxicity, anemia, and prolonged consumption of steroids. Functional outcome and quality of life indicators were prospectively recorded and compared. RESULTS: Patients in the ileostomy group had greater body surface area and older mean age at time of surgery, were taking greater doses of steroids preoperatively, and required more blood transfusions at the time of surgery compared with the one-stage (P < 0.05). There were no differences between the two groups in septic complications (P > 0.05). Early postoperative ileus was more common in the one-stage group (P < 0.001). There were no differences between the groups in quality of life and functional outcomes. CONCLUSIONS: For carefully selected patients undergoing restorative proctocolectomy with ileal pouch-anal anastomosis, omission of diverting ileost- omy is a safe procedure that does not lead to an increase inseptic complications or mortality. Quality of life and functional results are similar to those who undergo ileal pouch-anal anastomosis with diversion, provided that certain selection factors are considered.
