O'Connor Bi

Risk factors for pelvic pouch failure

PURPOSE: This study was designed to identify factors associated with pelvic pouch failure. METHOD: A retrospective review of patients undergoing the pelvic pouch procedure with a minimum of 30 months follow-up was conducted. RESULTS: A total of 551 patients had pelvic pouch procedures from 1981 to 1992. Forty-nine patients (8.8 percent) have undergone pouch excision, and 9 (1.6 percent) have been defunctioned, for 58 (10.5 percent) patients with pouch failure. Cause of failure was leakage from the ileoanal anastomosis (IAA) in 21 (39 percent) patients, poor functional results in 13 (23 percent), pouchitis in 7 (12 percent), pouch leakage in 7 (12 percent), perianal disease in 7 (12 percent), and miscellaneous in 3 (5.2 percent). Nine of 22 patients (41 percent) had pouch failure during the first two years, with 2 of 147 patients (1 percent) having failure during the last two years of the study. The 58 patients whose pouches failed (Group 1) were compared with the 493 patients whose pouches did not fail (Group 2). Handsewn IAA (P<0.001), tension on the IAA (P<0.001), use of a defunctioning ileostomy (P<0.01), a diagnosis of Crohns disease (P<0.001), and a leak from the pouch (P<0.001) or the IAA (P<0.001) were associated with pouch failure. Pouchitis was not a risk factor. CONCLUSION: The majority of pouch failures were caused by leaks at the IAA. Although the leak rate remained stable, leaks following a stapled anastomosis seemed to have a better prognosis than leaks following a handsewn anastomosis. Experience with the pouch procedure and the management of complications likely plays an important role in decreasing the risk of pouch failure.

Pregnancy, Delivery, and Pouch Function After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis

AbstractPURPOSE: This study was designed to evaluate the pregnancies, method of delivery, and functional results of females with chronic ulcerative colitis who have an ileal pouch-anal anastomosis. METHODS: A mailed questionnaire was sent to all females with an ileal pouch-anal anastomosis for chronic ulcerative colitis. Information on the pregnancy, method of delivery, and outcome was collected. Those females who had a successful pregnancy and delivery were contacted by telephone to clarify results and determine pouch functional results. Other clinical information was obtained from the Mount Sinai Hospital Inflammatory Bowel Disease database. RESULTS: Thirty-eight subjects had 67 pregnancies. Of these, 29 subjects had 49 deliveries. There were 25 vaginal deliveries and 24 cesarean sections. There were two pouch-related complications during the pregnancies and four pouch-related complications postpartum. All were treated nonoperatively. Stool frequency and day and night incontinence were increased during pregnancy in most subjects, but after delivery, prepregnancy function was restored in 24 (83 percent) of them. Five subjects (17 percent) had some degree of permanent deterioration in pouch function. Of these, three had vaginal deliveries, and two had cesarean sections. Multiple births and birth weight were not found to adversely affect subsequent pouch function. CONCLUSION: Pregnancy is safe in females with ileal pouch-anal anastomosis. Functional results are altered almost exclusively during the third trimester, but pouch function promptly returns to prepregnancy status in most females. A small proportion of females have long-term disturbances in function, but these are not related to the method of delivery. Thus, the method of delivery should be dictated by obstetric considerations.

Comparison of ileal pouch-anal anastomosis and ileorectal anastomosis in patients with familial adenomatous polyposis

PURPOSE: The aim of this study was to evaluate the surgical complications and long-term outcome and assess the functional results and quality of life after ileorectal anastomosis and ileal pouch-anal anastomosis in patients with familial adenomatous polyposis. METHODS: From 1980 to 1997, 131 patients with familial adenomatous polyposis were operated on or were followed up or both at the Familial Gastrointestinal Cancer Registry at Mount Sinai Hospital. Demographic and operative data were prospectively collected in the ileal pouch-anal anastomosis group, and retrospectively in the ileorectal anastomosis group. A questionnaire or telephone interview or both were undertaken to evaluate functional outcome and quality of life. RESULTS: The ileorectal anastomosis group consisted of 60 patients (mean age, 31 years; mean follow-up, 7.7 years). In the ileal pouch-anal anastomosis group there were 50 patients (mean age, 35 years; mean follow-up, 6 years). There were no statistically significant differences with respect to anastomotic leak rate in ileal pouch-anal anastomosisvs. ileorectal anastomosis (12vs. 3 percent;P=0.21), risk of small-bowel obstruction (24vs. 15 percent;P=0.58), and risk of intra-abdominal sepsis (3vs. 2 percent;P=0.86). Reoperation rate was similar in the two groups (14vs. 16 percent;P=0.94). Twenty-one patients (37 percent) with ileorectal anastomosis were converted to ileal pouch-anal anastomosis (12 patients) or proctocolectomy (9 patients), because of rectal cancer (5 patients), dysplasia (1 patient), or uncontrollable rectal polyps (15 patients). Two pelvic pouches were excised, and another one was defunctioned. Information regarding functional results and quality of life was obtained in 40 patients (66.6 percent) in the ileorectal anastomosis group and in 43 patients (86 percent) in the ileal pouch-anal anastomosis group. Patients with ileorectal anastomosis had a significantly better functional outcome with regard to nighttime continence and perineal skin irritation. But otherwise, functional results and quality of life were similar. CONCLUSIONS: Although ileorectal anastomosis has a better functional outcome, ileal pouch-anal anastomosis may be preferable because of the lower long-term failure rate. Ileorectal anastomosis is still an option in patients with familial adenomatous polyposis with rectal polyp sparing and good compliance for follow-up.

Reconstructive surgery for failed ileal pouch-anal anastomosis: a viable surgical option with acceptable results.

AbstractPURPOSE: Salvage procedures for failed ileal pouch-anal anastomoses frequently require total reconstruction with a combined abdominal and perineal approach. The aim of this study was to determine the indications for surgery and the outcomes in this group of patients. METHODS: All patients who underwent combined abdominal and perineal ileal pouch-anal anastomosis reconstruction at the Mount Sinai Hospital between 1982 and 2000 were reviewed. Data were collected prospectively in the inflammatory bowel disease database. RESULTS: Sixty-three reconstructive procedures were performed in 57 patients, with a mean age of 33.9 (±10.4) years at the time of reconstruction. There were 14 males. The mean follow-up was 69.1 months. The initial indication for ileal pouch-anal anastomosis was ulcerative colitis in 98 percent. The primary indication for reconstruction was pouch-vaginal fistula in 21 patients, long outlet in 14, pelvic sepsis in 14, ileoanal anastomotic stricture in 5, pouch-perineal fistula in 2, and chronic pouchitis in 1. The mean operative time was four hours (±1.1), the average blood loss was 500 mL (±400), and the average length of stay was 10.3 days (±4.6). All patients had a diverting ileostomy. Forty-two (73.6 percent) of the patients have a functioning pouch. Seven (12.3 percent) patients have had their pouch excised. The ileostomy has not yet been closed in 8 (14 percent) patients; 3 of these patients are awaiting closure, whereas the remaining 5 have a permanently defunctioning ileostomy. Eighty-nine percent have ten or fewer bowel movements per day. No patients are incontinent of stool during the day, whereas two patients are incontinent at night. Seventeen percent complain of frequent urgency. Despite this, more than 80 percent rate their physical and psychological health as good to excellent. CONCLUSION: Reconstructive pouch surgery has a high success rate in experienced hands. The functional results in those whose pouch is in use are good.

Pouch-Vaginal Fistula After Ileal Pouch-Anal Anastomosis: Treatment and Outcomes

PURPOSEPouch-vaginal fistula is an uncommon but serious complication after ileal pouch anal anastomosis. The management of pouch-vaginal fistulas is challenging and a number of treatment options exist. The purpose of this study was to examine the outcomes after various procedures for pouch-vaginal fistula performed at our institution.METHODSPatients who were treated for pouch-vaginal fistula at Mount Sinai Hospital were identified from a prospectively maintained database. Demographic, disease history, treatment, and outcomes data were obtained. Treatment success was defined as no recurrence of the fistula with a functioning pouch and no ileostomy.RESULTSSince November 1982, 24 of 619 (3.9 percent) women who had primary ileal pouch-anal anastomosis performed at Mount Sinai Hospital developed a pouch-vaginal fistula. Five women had ileal pouch-anal anastomosis performed at another institution and were referred for management of their pouch-vaginal fistula. Local and/or combined abdominoperineal repairs were performed in 22 of 29 patients. Combined abdominoperineal repairs were associated with a higher success rate than that of local perineal repairs (52.9 vs. 7.9 percent, respectively, at 10 years after repair; p = 0.035). Overall, 50 percent (11/22) of patients who underwent surgical repair of a pouch-vaginal fistula had a successful result with a functioning pouch and no recurrence of the fistula, and 21 percent (6/29) of patients required pouch excision.CONCLUSIONSThe management of pouch-vaginal fistula after ileal pouch-anal anastomosis is associated with a high recurrence rate. Combined abdominoperineal repair appears to offer better results than those of local procedures.

Functional outcome of conversion of ileorectal anastomosis to ileal pouch-anal anastomosis in patients with familial adenomatous polyposis and ulcerative colitis

PURPOSE: The aim of this study was to review the functional outcome in 20 patients with familial adenomatous polyposis and ulcerative colitis who were converted from ileorectal anastomosis to ileal pouch-anal anastomosis. METHODS: From 1985 to 1997, 12 patients with familial adenomatous polyposis (5 males; mean age, 39.1 years) and 8 patients with ulcerative colitis (5 males; mean age, 36.7 years) underwent conversion from ileorectal anastomosis to ileal pouch-anal anastomosis. Clinical and operative data were analyzed retrospectively. Functional results were obtained by telephone interview in 16 patients (94 percent) after pouch construction. Four patients were not interviewed (2 were deceased, 1 was lost to follow-up, and 1 was not reachable). RESULTS: Indications for conversion were uncontrollable rectal polyps (10 patients) and colonic cancer found in the pathology specimen after ileorectal anastomosis in patients with familial adenomatous polyposis (2 patients), intractable proctitis (5 patients), colonic cancer found in the pathology specimen of patients with ulcerative colitis after ileorectal anastomosis (2 patients), and rectal dysplasia (1 patients). Mean follow-up time was 5 (range, 1–11) years. Ileal pouch-anal anastomosis was handsewn in 14 patients, and the remaining cases were double-stapled in 4 patients with ulcerative colitis. No intraoperative difficulties were reported in 13 cases; technical problems were related to adhesions (3 cases), difficult rectal dissection (2 cases), and stapler-related difficulties (2 cases). Postoperative complications after ileal pouch-anal anastomosis included small-bowel obstruction (4 patients) and ileal pouch-anal anastomosis leak (1 patient). Patients with ileorectal anastomosisvs. those with ileal pouch-anal anastomosis had a better functional outcome with regard to nighttime continence (14 (88 percent)vs. 6 (38 percent) patients) and average bowel movements (<6/day; 12 (75 percent)vs. 4 (25 percent) patients). Complete daytime continence, 15 (94 percent)vs. 10 (62 percent) patients, was similar in the two groups. Physical and emotional well-being were similarly rated as very good to excellent. CONCLUSIONS: In patients with familial adenomatous polyposis and ulcerative colitis with ileorectal anastomosis, conversion to ileal pouch-anal anastomosis may be required. In view of the risk of rectal cancer or intractable proctitis, patients seem to accept the conversion in spite of poorer bowel function.

Outcome of patients undergoing liver transplantation for primary sclerosing cholangitis.

AbstractPURPOSE: The purpose of this study was to determine the outcome of patients with inflammatory bowel disease who underwent liver transplantation for primary sclerosing cholangitis. METHODS: All patients who underwent liver transplantation for primary sclerosing cholangitis at our institution were identified. A review of patients’ hospital and office charts was performed; all patients were then contacted, and a detailed survey was administered by telephone. RESULTS: Sixty-nine patients were identified. There were 53 males (76.8 percent) and 16 females, with a mean age of 45.3 (± 13.3) years. Fifty-two (75.4 percent) of the 69 patients had documented inflammatory bowel disease; of these, 40 had ulcerative colitis (76.9 percent), 11 had Crohn’s disease, and 1 had indeterminate colitis. Thirty-one patients (60 percent) were diagnosed with inflammatory bowel disease before primary sclerosing cholangitis, with a mean interval to diagnosis of primary sclerosing cholangitis of 10.8 (± 10.3) years. Seven patients had both diagnoses made at roughly the same time, and 14 patients initially were diagnosed with primary sclerosing cholangitis and subsequently were found to have inflammatory bowel disease, with a mean interval of 5.2 (± 4.4) years; 5 (35.7 percent) of those 14 patients were only diagnosed with inflammatory bowel disease after their liver transplant. The mean time from diagnosis of primary sclerosing cholangitis to liver transplantation was 6.1 (± 4.9) years. Since their transplant, 30.8 percent of patients rated their colitis as worse, 38.5 percent felt it was unchanged, and 30.8 percent felt that their colitis was better controlled. Eight (15.4 percent) of the 52 patients with inflammatory bowel disease denied having any knowledge of an increased risk of colorectal neoplasia. Four patients have required colectomy for colorectal neoplasia after liver transplantation, at a mean of 4.7 years after transplantation. Of the patients with inflammatory bowel disease, 42 (80.1 percent) had at least 1 posttransplant surveillance colonoscopy. Eight of the remaining ten patients had a colectomy, leaving only two patients (3.8 percent) who had not been surveyed. However, only 32 (61.5 percent) of the patients with inflammatory bowel disease have been on a surveillance regimen that would approximately conform to current screening recommendations. CONCLUSIONS: The activity of inflammatory bowel disease after transplantation is highly variable. Patients appeared to lack knowledge of their increased risk for colorectal neoplasia. Colorectal cancer is an uncommon but important complication in patients after liver transplantation for primary sclerosing cholangitis, and ongoing surveillance is required. Patients may require education to increase their awareness of the cancer risk and compliance with surveillance.

Sepsis is a Major Predictor of Failure After Ileal Pouch-Anal Anastomosis

PURPOSE: This study aimed to determine the risk of ileal pouch-anal anastomosis failure and factors predictive of failure overall and in patients with septic complications. METHODS: Patients were identified through a prospectively maintained patient registry. All patients registered in the Mount Sinai Hospital Inflammatory Bowel Disease database who had an ileal pouch-anal anastomosis for more than 12 months were included in the study. Pouch failure was defined as ileal pouch-anal anastomosis excision or permanent diversion. Cox proportional hazard models with death as a competing risk were created, modeling time to failure as the outcome of interest for all patients and for the subgroup of patients with septic complications. RESULTS: The study included 1,554 patients. One hundred six patients experienced an ileal pouch-anal anastomosis failure (6.8%), 49 (46.2%) of these failures were caused by septic complications. Independent predictors of failure included Crohn’s disease (hazard ratio 7.5, 95% confidence interval [4.7, 12.0]) and postoperative sepsis (hazard ratio 6.6, 95% confidence interval [4.4, 9.8]). In the subgroup of patients with failure due to postoperative septic complications, independent predictors of failure were Crohn’s disease (hazard ratio 2.7, 95% confidence interval [1.3, 5.7]) and presence of a pouch fistula (hazard ratio 2.6, 95% confidence interval [1.3, 5.2]). CONCLUSION: Septic complications are the most common cause of ileal pouch-anal anastomosis failure. Careful patient selection and the prevention of septic complications may decrease the risk of this failure.

Outcomes following surgery for perforating Crohn's disease

The most common indications for surgery for patients with ileocolic Crohns disease are fibrostenotic or perforating disease. The objective was to compare surgical outcomes of patients with perforating versus non‐perforating disease following ileocolic resection.

Favorable pathologic and long-term outcomes from the conventional approach to abdominoperineal resection.

BACKGROUND: Suboptimal oncologic outcomes from abdominoperineal resection have been related to high rates of circumferential margin involvement. The extralevator approach has gained popularity as a means of reducing circumferential margin involvement, but it remains unknown whether comparable outcomes are achievable with a conventional approach to abdominoperineal resection. OBJECTIVE: This study aimed to determine the rate of circumferential margin involvement, to identify factors predictive for a positive circumferential margin, and to relate these findings to long-term outcomes. DESIGN: This is a retrospective analysis of a prospective clinical database. SETTINGS: This study was conducted at a single center, Mount Sinai Hospital, Toronto. PATIENTS: Patients were included who underwent abdominoperineal resection for low rectal adenocarcinoma between 1997 and 2006. MAIN OUTCOME MEASURES: The main outcome measures included the rate of circumferential margin involvement, local recurrence, and disease-free survival. RESULTS: A total of 115 patients underwent abdominoperineal resection for primary adenocarcinoma of the rectum. A positive circumferential margin was demonstrated in 18 patients (15.7%). Intraoperative perforations occurred in 7 patients (6.1%). Tumors located anteriorly had a higher rate of circumferential margin involvement (31.6%) compared with lateral (13%), posterior (10%), and circumferential tumors (0%) (P = .024). This finding was reflected by a reduced median distance to the circumferential margin in anterior tumors. Curative resections (n = 108) were followed up for a median of 55.5 months. The 5-year local recurrence rate was 10.6% and the 5-year disease-free survival was 67.4%. Cox regression analysis revealed that circumferential margin involvement was an independent predictor for local recurrence; and T-category, N-category, and circumferential margin involvement for disease-free survival. LIMITATIONS: This study was limited by its sample size and the number of outcome events. CONCLUSIONS: The conventional approach to abdominoperineal resection can produce oncologic outcomes comparable to the extralevator approach. However, the rate of circumferential margin involvement is higher than in restorative procedures and may be related to difficulties in obtaining adequate clearance in anterior tumors.