P. R. Hawley

Long-term failure after restorative proctocolectomy for ulcerative colitis

Objective To establish the incidence and causes of late failure in patients undergoing restorative proctocolectomy for a preoperative diagnosis of ulcerative colitis was the objective of this investigation. Summary Background Data Restorative proctocolectomy is the elective surgical procedure of choice for ulcerative colitis. Most patients have a satisfactory outcome but failures occur. The reasons and rates of early failure are well documented, but there is little information on long-term failure. Methods A series of 634 patients (298 females, 336 males) underwent restorative proctocolectomy for inflammatory bowel disease between 1976-1997, with a mean follow-up of 85 ± 58 months. Failure was defined as removal of the pouch or the need for an indefinite ileostomy. It was divided into early and late, occurring within 1 year or more than 1 year postoperatively. Results There were 3 (0.5%) postoperative deaths, leaving 631 patients for analysis. Of these, 23 subsequently died (disseminated large bowel cancer, 12; unrelated causes, 9; related causes, 2). There were 61 (9.7%) failures (15 early [25%], 46 late [75%]) due to pelvic sepsis (32 [52%]: 7 early, 25 late), poor function (18 [30%]: 2 early, 16 late), pouchitis (7 [11%]: 2 early, 5 late) and miscellaneous (4, all early). A final diagnosis of Crohns disease, type of reservoir (J,S), female gender, postoperative pelvic sepsis and a one-stage procedure were significantly associated with failure. Failure rate rose with time of follow-up from 9% at 5 years to 13% at 10 years. Conclusions Pelvic sepsis and poor function were the main reasons for later failure. Failure rates should be reported based on the duration of follow-up.

Lower gastrointestinal malignancy in Crohn's disease.

An increased incidence of carcinoma of the small bowel and colon has been described in patients with Crohns disease. Tumours arising in the rectum and anus are reported less often. Between 1940 and 1992, of some 2500 patients with Crohns disease seen at this hospital, 15 are known to have developed carcinoma of the lower gastrointestinal tract. Malignancy occurred in the colon in two patients, in the upper two thirds of rectum in one, in the lower third of rectum in seven, and in the anus in five. The 12 patients with carcinoma arising in the anus or lower rectum had longstanding severe anorectal Crohns disease, which included a stricture in four, fistula in four, proctitis in one, abscess in two, and enlarged anal skin tags in one. The development of malignancy in patients with Crohns disease may apply particularly to those with chronic complicated anorectal disease.

The first 10 years' experience of restorative proctocolectomy for ulcerative colitis.

Between 1976 and 1985, 110 patients had restorative proctocolectomy or proctectomy for ulcerative colitis and 103 were followed up until death or February 1992. There was one postoperative and one late death related to surgery. The cumulative probability of pouch failure was 12% at five years: half of the failures occurred within one year. The commonest reasons were perianal/pelvic sepsis and probable Crohns disease. The cumulative probability of readmission, excluding that for ileostomy closure, was 68% at five years. There were 152 operations carried out during readmissions. These included 44 laparotomies. Function was assessed in 80 patients at a mean of 99.3 months after ileostomy closure. For 66 patients with spontaneous evacuation, average minimum diurnal frequency was 3.8, maximum 4.9, with 35 evacuating at night. One patient experienced major continence problems, 30 had minor leaks, and 49 were completely continent. Postoperatively, five patients gave birth to nine babies, four had renal stones, two myasthenia gravis, and two severe anaemia: seven had pre or postoperative thyroid dysfunction.

Internal anal sphincter repair.

Abstract. The results of repair to the internal and sphincter alone has been evaluated in five patients with persistent anal incontinence following surgery which affected the internal anal sphincter. All had passive incontinence for solid or liquid stool. Symptoms, anorectal manometry, and anal endosonography were evaluated before and after surgery. After surgery three patients felt improved but had still persistent symptoms, and no patients achieved full continence. Three patients showed an increased maximal and resting pressure, but only one of them was within the normal range. Post operatively, all the anal ultrasound scans showed a persistent internal sphincter defect, and two showed an unsuspected external anal sphincter defect. Although some patients felt symptomatically improved, the overall clinical, manometric and radiological findings after internal and sphincter repair were disappointing.Résumé. Les résultats de la réparation isolée du sphincter interne ont étéévalués chez cinq patients présentant une incontinence anale persistante après un geste chirurgical ayant lésé le sphincter interne. Tous présentaient une incontinence passive pour les solides et les liquides. Les symptômes, les résultats de la manométrie ano-rectale et de léchographie endo-anale ont étéévalués avant et après correction chirurgicale. Après lintervention, trois patients se disent améliorés mais présentent toujours des symptômes persistants; aucun patient na retrouvé une continence complète. Trois patients présentent une augmentation de la pression de repos et de la pression de contraction maxi-male mais chez un seul patient, ces valeurs sont dans la limite de la norme. En post-opératoire, léchographie endo-anale montre une persistance du défect du sphincter interne chez tous les cas et dans deux, cet examen met en évidence une lésion méconnue du sphincter externe. Bien que quelques patients se sentent améliorés, les résultats cliniques manométriques et radiologiques après réparation du sphincter anal interne sont décevants.

Surgery for ulcerative colitis in the era of the pouch: the St Mark's Hospital experience.

The choice of operation for ulcerative colitis among 422 patients having all their surgery at one hospital between 1976 (the year of the first restorative proctocolectomy) and 1990, was reviewed. The 15 year period was divided into three quinquennia (1976-80, 1981-85, 1986-90). Elective surgery was performed in 316 patients with one operative death. The proportions of conventional proctocolectomy, colectomy with ileorectal anastomosis, and restorative proctocolectomy for the three quinquennia were 36/60, 17/60, 4/60; 29/111, 30/111, 35/111; 30/145, 17/145, 75/145. Of 106 urgent operations with three postoperative deaths, 12 had a conventional proctocolectomy and 86 a colectomy with ileostomy and preservation of the rectum. Of 85 survivors of the latter there were two late deaths and in 13 no further surgery had been done at the time of this assessment. In the remaining 70 having subsequent surgery the proportion of conventional proctocolectomy, colectomy with ileorectal anastomosis, and restorative proctocolectomy for the three quinquennia respectively were 19/27, 4/27, 14/27; 11/21, 2/21, 8/21; 5/22, 4/22, 13/22. Of the 76 patients having colectomy with ileorectal anastomosis 12 (16%) no longer had a functioning rectum at the end of 1990. Of the 153 patients having an ileoanal pouch procedure, 11 (7%) no longer had, a functioning anus. The study showed an increase in the numbers of patients having elective surgery for ulcerative colitis during the three quinquennia. It also showed a rise of restorative over conventional proctocolectomy with diminution in elective colectomy with ileorectal anastomosis in the last five year period.

Colectomy for idiopathic megarectum and megacolon.

The outcome in 40 patients who underwent colectomy for idiopathic megacolon and megarectum over an 18 year period was evaluated. All patients had a radiologically dilated bowel and a bowel frequency of less than two per week. Twenty two patients had a caecorectal anastomosis, 11 had an ileorectal anastomosis (including one with a previous caecorectal anastomosis and four with a previous sigmoid resection), and seven had a sigmoid resection. The mean (range) age at operation was 35 (17-69) years. All three operations resulted in a normal bowel frequency in more than 80% of patients but no patient with an ileorectal anastomosis experienced recurrent constipation. Thirty four patients experienced pain preoperatively and this was still present in 14 patients postoperatively. One patient died and four required subsequent laparotomy for bowel obstruction. The functional outcome in patients with dilatation of the whole colon and in those with dilatation of the left colon did not differ. Subsequent surgery for constipation was performed in three patients. Colectomy offers good results with few complications in the treatment of idiopathic megacolon, and an ileorectal anastomosis is the preferred operation.

Strictureplasty: a good operation for small bowel Crohn's disease?

Seven patients with widespread, active, stricturing, small intestinal Crohns disease and two with localized disease were treated by a total of 45 strictureplasties. They have been followed up for a mean of 20 months (range 6 to 30). Two patients had early postoperative complications with enterocutaneous fistulas, one of which may have been related to a strictureplasty. The two patients with localized disease remain well after 16 and 30 months. Of the seven patients with extensive small bowel disease, two are well six and 28 months after surgery. Recurrent symptoms developed in six patients two to six months postoperatively; four of those patients required further surgery. Previous reports of strictureplasty in inactive Crohns strictures suggest it is a safe operation with good long-term results. Strictureplasty in active Crohns disease has a much higher recurrence rate of symptoms. Because it is a conservative operation, however, we believe it has a place in the surgical treatment of Crohns disease.

Stenosis of the pouch anal anastomosis following restorative proctocolectomy

Purpose: To compare the incidence of stenosis after hand-sewn and stapled ileoanal anastomosis. Stenosis of the ileoanal anastomosis occurs in 5–16% of patients undergoing a restorative proctocolectomy but the incidence using a stapled technique is unknown.Methods: Between 1976 and 1990, 266 patients underwent restorative proctocolectomy or proctectomy at one hospital. In two hundred and eighteen the anastomosis was hand sewn and stapled in 48 (single 33; double 15).Results: Stenosis occurred in 31 (14.2%) of the hand-sewn and in 19 (39.6%) of the stapled anastomoses. This difference was highly significant (P<0.001). Stenosis was not related to the size of the staple head used or to the stapling technique. There was no relationship between the development of stenosis and pelvic sepsis. Twenty six (hand-sewn 16, stapled 10) of the 48 patients with stenosis needed dilatation under general anaesthetic.Conclusion: Stapled anastomoses may result in a high incidence of anastomotic stenosis.RésuméLe but du travail est détudier lincidence des sténoses post-opératoires danastomoses iléo-anales réalisées soit à la main, soit au moyen dagrafeuses. Une sténose de lanastomose iléo-anale survient dans 5 à 16% des patients qui subissent une proctocolectomie restaurative mais lincidence résultant dune technique par agrafage est inconnue.Méthode: Entre 1976 et 1990, 266 (deux-cent soixante six) ont subi dans la même institution une proctocolectomie ou une proctectomie avec rétablissement de la continuité. Lanastomose a été réalisée de manière manuelle chez 218 (deux cent dix huit) patients et à laide dagrafeuse chez 48 (agrafage simple: 33; agrafage double: 15).Résultat: Une sténose est survenue chez 31 (14,2%) des anastomoses manuelles et chez 19 (39,6%) des anastomoses mécaniques. La différence était hautement significance (P<0.001). La sténose nest pas à mettre en relation avec le diamètre de la tête dagrafage utilisée ou la technique dagrafage. Il ny a pas de relation entre le développement dune sténose et une affection pelvienne. Vingt-six des 48 patients porteurs de sténose (16 anastomoses manuelles et 10 anastomoses mécaniques) ont nécessité une dilatation sous anesthésie générale.Conclusion: Lagrafage mécanique peut entraïner une incidence élevée de sténose anastomotique lors danastomose iléo-anale.

Partial colectomy and coloanal anastomosis for idiopathic megarectum and megacolon

Adult patients with an idiopathic megarectum or megacolon can experience severe constipation requiring surgical treatment. Some of these patients have a proximal colon of normal diameter, with dilatation involving only the left or distal colon and rectum. The results of partial colonic and rectal resection with coloanal anastomosis in such patients have been reviewed. Seven patients (two female and five male) underwent a coloanal anastomosis over a seven-year period. The median age at operation was 19 years, the mean age at onset of symptoms was five years, and the mean follow-up period was one year. Five patients experienced a return to normal bowel frequency with the loss of most symptoms. One patient has an ileostomy because of persistent constipation after the procedure. One subject died because of postoperative bleeding from the anastomosis and subsequent cardiac and respiratory complications. This operation may have a place in the treatment of severe constipation caused by idiopathic megarectum and megacolon, but careful preoperative motility studies and meticulous attention to operative technique are required for a good outcome.

LEFT HEMICOLECTOMY WITH RECTAL EXCISION FOR SEVERE IDIOPATHIC CONSTIPATION

The standard surgical therapy for severe idiopathic constipation is total colectomy with ileorectal anastomosis, but this results in intractable diarrhoea in a third of the patients and recurrent constipation in another 10%. Studies which employ either radio-isotopes or radio-opaque markers permit the delineation of regional delay in colonic transit. Based on these studies, and evidence that the rectum is also abnormal in these patients, we have performed a left hemicolectomy with rectal excision in 2 patients with proven left colonic delay. After 2 and 3 years of follow-up, both patients have normal frequency, transit studies and anorectal physiology studies. Segmental resection based on physiological studies may offer better relief of symptoms with a lower chance of side effects in selected patients.RésuméLe traitement chirurgical classique de la constipation sévère idiopathique est la colectomie totale avec anastomose iléorectale mais un tiers des patients ont secondairement une diarrhée importante et 10% constipés. Les études utilisant des marqueurs isotopiques ou radioopaques permettent de préciser la topographie du ralentissement du transit colique. Compte tenu de ces travaux et du fait que le rectum est également anormal chez ces patients, nous avons réalisé une hémicolectomie gauche avec excision rectale chez deux patients ayant un ralentissement colique gauche prouvé. Après deux et trois ans de suivi, ces patients ont un transit normal évalué sur les donnés radiologiques et manométriques. La résection colique segmentaire, basée sur des études physiologiques, peuvent offrir une meilleure amélioration symptômatique au prix deffets secondaires moindres chez des patient sélectionnés.