E. H. Allemeyer

Risk factors for ileoanal J pouch-related septic complications in ulcerative colitis and familial adenomatous polyposis

ObjectiveTo analyze the association between pre- and perioperative factors and pouch-related septic complications (PRSC) in ulcerative colitis (UC) and in familial adenomatous polyposis (FAP) after ileal pouch–anal anastomosis (IPAA). Summary Background DataFor patients with UC and FAP, IPAA is the surgical therapy of choice, but in some patients the outcome is compromised by PRSC. MethodsA total of 706 consecutive patients (494 UC, 212 FAP) were assessed in a study aimed at identifying subgroups of patients who were at high risk for PRSC. The rate of PRSC was analyzed as a time-dependent function (Kaplan-Meier estimation). Patients with UC and FAP were stratified separately according to associated factors (age, sex, surgeon’s experience, temporary ileostomy, colectomy before IPAA, anastomotic tension, and several factors specific for UC). ResultsIn all, 131 (19.2%) patients had PRSC (23.4% UC, 9.4% FAP). In patients with UC, the estimated 1-year PRSC rate was 15.6% and the estimated 3-year PRSC rate was 24.2%. In patients with FAP, the estimated 1-year and 3-year PRSC rates were 9.2%. The difference between the estimated rates of PRSC was significant (P < .001). In the univariate analysis, patients with UC younger than 50 years, with severe proctitis, with preoperative hemoglobin levels less than 10 g/L, or receiving corticoid medication had a significantly higher risk for PRSC (P = .039, P = .037, P = .047, P = .003, respectively). Multivariate analysis showed that patients with UC receiving a systemic prednisolone-equivalent corticoid medication of more than 40 mg/day had a significantly greater risk of developing pouch-related complications than patients with UC receiving 1 to 40 mg/day and patients with UC who were not receiving corticoid medication (RR: 3.78, 2.25, 1, respectively, P < .001). Patients with FAP proved to have a significantly higher risk for PRSC in the univariate and multivariate analyses if anastomotic tension had occurred (RR 3.60, P = .0086). ConclusionsPouch-related septic complications occur as late complications and should therefore be considered in regular, specific long-term follow-up examinations. The authors identified significant risk factors for PRSC specific to patients with UC and FAP; these must be considered for each individual surgical strategy.

One- or two-stage procedure for restorative proctocolectomy: Rationale for a surgical strategy in ulcerative colitis

ObjectiveTo analyze the results of different strategies for restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) in ulcerative colitis. Summary Background DataNo commonly accepted criteria exist for choosing between the one-stage or the two-stage procedure (with or without temporary diverting ileostomy) for IPAA. The authors analyzed the outcome of patients principally suitable for either of the two alternative surgical strategies. MethodsA matched-pair control study was performed, comparing surgical details and the early and late outcome of the one-stage (study group, n = 57) versus the two-stage procedure (control group, n = 114), for IPAA. ResultsNo differences were found between the study group and the control group regarding the matching criteria gender, median age at IPAA, systemic corticoid medication, or activity of colitis. Comparing the patients who underwent a one-stage procedure with those who underwent a two-stage procedure, the proportion of patients without complications was significantly higher (P = .0042) and the frequency of late complications was significantly lower (P = .0022) in patients who underwent the one-stage procedure. The percentage of patients with anastomotic strictures was significantly higher in the control group than in the study group (P = .0022). No significant difference was found between the two groups regarding early complications, pouch-related septic complications, pouchitis, median duration of surgery for IPAA, median blood loss, need for transfusion, or median hospital stay. ConclusionsIn patients with ulcerative colitis in whom there is a choice between a one-stage procedure or a two-stage procedure with a defunctioning ileostomy, the one-stage procedure is clearly superior. This finding is of great clinical relevance both for the subjective interests of the patient and from an economic point of view.

Adenocarcinoma in the ileal pouch: late risk of cancer after restorative proctocolectomy.

Restorative proctocolectomy and ileal pouch–anal anastomosis is the surgical treatment of choice for patients with ulcerative colitis. As a long-term complication of this procedure, chronic pouchitis impairs the outcome in a number of patients. Aneuploidia and dysplasia have been observed after long-lasting inflammation of ileal mucosa. The question arises whether chronic inflammation of ileal mucosa predisposes to malignant transformation similar to the situation in the chronically inflamed colon. Cancer of the ileal mucosa has been reported in patients with Brookes ileostomy and in patients with Kock pouch but not as yet in those with an ileoanal pouch. We report a patient with carcinoma in an ileoanal pouch originating from terminal ileal mucosa who had been suffering from pancolitis with long-term backwash ileitis before, and from chronic pouchitis after, restorative proctocolectomy. This case demonstrates the importance of regular follow-up with pouchoscopy and random biopsies in all patients with long-standing inflammation of the ileal mucosa.

Long-term follow-up after ileoanal pouch procedure

PURPOSE: Inflammation of the ileoanal pouch (pouchitis) is one of the main complications after restorative proctocolectomy, yet its cause remains poorly understood. A standardized definition and diagnostic procedures in pouchitis are lacking. METHOD: We analyzed all cases of pouchitis occurring in a group of 308 patients (210 with ulcerative colitis, 98 with familial adenomatous polyposis) who took part in a prospective long-term follow-up program. The severity of pouchitis was measured using a pouchitis activity score (Heidelberg Pouchitis Activity Score). An algorithm for the classification and management of pouchitis was established which enables the clinician: 1) to determine theseverity of pouchitis, 2) to differentiate betweenprimary pouchitis and pouchitis caused by surgical complications (secondary pouchitis), and 3) to evaluate the course (acute vs. chronic (>3 months)). RESULTS: The median duration of follow-up was 48 (range, 13–119) months. At least one episode of pouchitis was diagnosed in 29 percent of patients with ulcerative colitis and in 2 percent of familial adenomatous polyposis patients. Secondary pouchitis occurred in 6 percent of ulcerative colitis patients and was cured by surgical treatment in 13 (87 percent) of 15 cases. Primary pouchitis was diagnosed in 23 percent of ulcerative colitis patients, including 6 percent of all ulcerative colitis patients with chronic primary pouchitis. The latter showed poor response to medical treatment. In one case multifocal high-grade dysplasia occurred. Histologic examination of the excised pouch identified a carcinoma originating from the ileal mucosa. CONCLUSIONS: Ulcerative colitis patients after restorative proctocolectomy face a high risk of developing pouchitis. The algorithm used in this study was highly efficient in identifying patients with a secondary pouchitis who require surgical treatment and patients with chronic primary pouchitis. For the latter, long-term surveillance seems mandatory because of the risk of malignant transformation of the pouch mucosa.

diagnosing Pouchitis : comparative Validation of Two Scoring Systems in Routine Follow-up

AbstractPURPOSE: Pouchitis represents a serious threat to patients with ulcerative colitis after restorative proctocolectomy with ileal pouch-anal anastomosis. The frequency of pouchitis is high, and it implies the risk of pouch failure and the risk of malignant mucosal transformation in the pouch. Early detection and precise classification of the inflammatory process are required for adequate therapy, which might be facilitated using a scoring system. The aim of the present study was to validate two existing scoring systems in routine outpatient practice. METHOD: The Heidelberg Pouchitis Activity Score and the Pouchitis Disease Activity Index developed at the Mayo Clinic were simultaneously prospectively applied in a consecutive series of 103 outpatient consultations of 41 patients at our hospital and comparatively validated against the diagnosis of “ pouchitis” or “no pouchitis” concurrently made by a physician and a surgeon. RESULTS: The median score of examinations in which the clinicians’ diagnosis was consistent with pouchitis were significantly higher than those of examinations inconsistent with pouchitis in both scoring systems (Heidelberg Pouchitis Activity Score, 17 (interquartile range, 14–21) and 8 (interquartile range, 5–10), respectively, P < 0.001; Pouchitis Disease Activity Index, 7 (interquartile range, 5–8) and 2.5 (interquartile range, 1–4), respectively, P < 0.001). The sensitivity and specificity in the two total scores were 84 and 79.5 percent, respectively (Heidelberg Pouchitis Activity Score), and 60 and 96.2 percent, respectively (Pouchitis Disease Activity Index); in the field clinical manifestations 44 and 73.1 percent, respectively (Heidelberg Pouchitis Activity Score), and 20 and 87.2 percent, respectively (Pouchitis Disease Activity Index); in the field endoscopic manifestations 88 and 83.3 percent, respectively (Heidelberg Pouchitis Activity Score), and 60 and 89.7 percent, respectively (Pouchitis Disease Activity Index); and in the field histologic manifestations 72 and 76.9 percent, respectively (Heidelberg Pouchitis Activity Score), and 44 and 96.2 percent, respectively (Pouchitis Disease Activity Index). Lowering the cutoff point for diagnosis of pouchitis in the Pouchitis Disease Activity Index by 2 points (pouchitis: score ≥ 5) would result in an 88 percent sensitivity and a 67 percent specificity. CONCLUSIONS: Specificity and sensitivity of the Heidelberg Pouchitis Activity Score were satisfactory. The cutoff point for diagnosing pouchitis in the Pouchitis Disease Activity Index would have to be lowered to reach an acceptable sensitivity and specificity. The very poor validity of the field clinical manifestations in diagnosing pouchitis emphasizes the need for endoscopic and histologic examination for detection of pouchitis. The issue of whether the diagnosis of pouchitis should be based on endoscopic and histologic features alone, instead of additionally taking clinical features into account, should be addressed in future studies.

Glutamine distribution in patients with ulcerative colitis and in patients with familial adenomatous polyposis coli before and after restorative proctocolectomy

Abstract. Background and aims: Restorative proctocolectomy with construction of an ileoanal pouch (IPAA) is the surgical treatment of choice for patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP). This procedure imposes an essential change in function on the terminal ileal mucosa and pouch mucosa. Glutamine is one of the major nutrients for the small-bowel mucosa; it is metabolized into glutamate and subsequently alanine in the human enterocyte. In a prospective clinical trial we compared glutamine distribution in patients with UC to that in patients with FAP before and after restorative proctocolectomy. Methods and patients: Concentrations of glutamine, glutamate, and alanine were measured pre- and postoperatively in the terminal ileal mucosa, pouch mucosa, skeletal muscle and venous blood of patients undergoing IPAA for UC or FAP. Healthy individuals served as controls for skeletal muscle glutamine concentration. Results: After IPAA the glutamine concentration in UC patients was decreased in skeletal muscle. In the mucosa glutamine remained unaltered while glutamate and alanine concentrations increased. In plasma the glutamine concentration increased, the glutamate level fell, and the alanine level increased. In FAP patients the glutamine level was unchanged in skeletal muscle after IPAA. In mucosa the glutamine level did not change, but glutamate and alanine increased. In plasma the glutamine level remained unaltered, glutamate decreased, and alanine increased. Conclusion: Patients with UC or FAP before surgical therapy do not suffer from glutamine depletion. IPAA resulted in changes in the distribution of glutamine and its metabolites in skeletal muscle, plasma, and ileal pouch mucosa, particularly in patients with UC. Further studies should investigate whether characteristics in the glutamine distribution have any impact for the long-term outcome after IPAA.

Pouchitis nach Restaurativer Proktokolektomie: Komparative Validierung zweier Scoring-Systeme in der klinischen Nachsorge

Die Pouchitis gehort zu den haufigsten Komplikationen nach ileoanaler Pouchanlage. Es konnen schwere Einschrankungen der Lebensqualitat bis hin zum Pouchversagen resultieren. Auch eine maligne Entartung der Pouchschleimhaut ist moglich. Eine adaquate Therapie der Pouchitis erfordert eine fruhzeitige und prazise Diagnose. Validierte Scoring-Systeme sind bislang nicht verfugbar. Das Ziel der vorliegenden Studie ist, zwei etablierte Scoring-Systeme in der klinischen Routine-Nachsorge vergleichend zu validieren. Material und Methode:Der Heidelberg Pouchitis Activity Score (PAS) und der Pouchitis Disease Activity Index (PDAI) der Mayo Clinic wurden prospektiv gleichzeitig bei 103 konsekutiven ambulanten Konsultationen eingesetzt. Beide Scoring-Systeme setzen sich aus den 3 Elementen Klinik, Endoskopie und Histologie zusammen. Die Gesamtscores sowie die einzelnen Elemente wurden gegenuber der unabhangigen Diagnose („Pouchitis“ oder „keine Pouchitis“) zweier Kliniker (1 Internist und 1 Chirurg) validiert. Ergebnisse:In beiden Scores war die mediane Punktzahl von Patienten, bei denen die Kliniker eine Pouchitis diagnostiziert hatten, signifikant hoher als bei Patienten, ohne Pouchitis [PAS: 17 (IQR 14 -21) bzw. 8 (IQR 5 - 10), p < 0.001; PDAI: 7 (IQR 5-8) bzw. 2.5 (IQR 1 - 4), p < 0.001]. In den Gesamtscores von PAS und PDAI lagen die Sensitivitat und Spezifitat bei 84% und 79.5%, bzw. 60% und 96.2%, im Abschnitt Klinik 44% und 73.1%, bzw. 20% und 87.2%, im Abschnitt Endoskopie 88% und 83.3%, bzw. 60% und 89.7% und im Abschnitt Histologie 72% und 76.9% bzw. 44% und 96.2%. Durch ein Absenken der Punkteschwelle fur die Diagnose der Pouchitis im PDAI um 2 Punkte wurde sich eine Gesamtsensitivitat von 88% und eine Gesamtspezifitat von 67% ergeben. Schlusfolgerungen:Der PAS hat eine ausreichende Spezifitat und Sensitivitat, dagegen muste die Punkteschwelle fur die Diagnose „Pouchitis“ im PDAI gesenkt werden. In beiden Scores zeigt der Abschnitt Klinik eine sehr geringe Validitat. Eine Pouchitis darf deshalb nur auf Grundlage zusatzlicher endoskopischer und histologischer Befunde diagnostiziert werden.

lleoanaler Pouch (lAP) im Kindesalter: Indikation, Ergebnisse und Lebensqualität

Die Indikation zur Kolektomie wird von Padiatern nur sehr zuruckhaltend gestellt. Bei Kindern stellt die IAP noch kein Standardverfahren dar und wird nur an wenigen Zentren in sehr kleinen Fallzahlen durchgefuhrt. Entsprechend sparlich sind Literaturangaben. Material und Methode:Von 1986 bis 12/2000 wurden an der Chirurg. Univ.-Klinik HD 50 Kinder (CU n = 34; FAP n = 16) restaurativ proktokolektomiert. Alle Kinder wurden prospektiv erfast. Die Nachsorge erfolgte standardisiert (med. NBZ 4,9 J. (0,5-14 J.)). Die Lebensqualitat (LQ) wurde mit einem kindgerecht modifizierten LQ-Score gemessen. Ergebnisse:Die Indikation zur IAP wurde bei CU-Kindern in 88,2% wegen Wachstumsretardierung, in 55,9% wegen schwerer Medikamenten-NW, in 23,5% wegen therapierefraktarem Verlauf und in 2,9% wegen Dysplasien gestellt (Mehrfachnennung). Die FAP-Kinder wurden in allen Fallen wegen ausgepragter Symptomatik (Blutung, Tenesmen) operiert, zusatzlich bestanden bei 2 Kindern Epithelatypien (Tabelle 1).