Roger R. Dozois

Vascular Complications of Inflammatory Bowel Disease

During an 11-year period from January 1970 to December 1980, 7,199 patients at our institution had chronic ulcerative colitis or Crohns disease. Thromboembolic complications developed in 92 (1.3%) of these patients. An additional 4 patients had cutaneous vasculitis, and 17 had an arteritis-associated diagnosis. Of the thromboembolic complications, 61 were deep vein thromboses or pulmonary emboli. The mortality among patients with thromboembolic complications was high (25%). Sixty percent of the patients had a thrombocytosis unaffected by sulfasalazine or corticosteroid therapy. In 73% of the patients, the erythrocyte sedimentation rate was increased, and when measured, fibrinogen and factor VIII were commonly elevated. Peripheral arterial thrombosis, coronary thrombosis, and mesenteric and portal vein thrombosis were predominantly postsurgical complications, but 77% of peripheral venous thromboses occurred spontaneously. The role of anticoagulation and surgical intervention in the management of hypercoagulation in patients with inflammatory bowel disease is discussed.

Pouchitis after ileal pouch-anal anastomosis for ulcerative colitis occurs with increased frequency in patients with associated primary sclerosing cholangitis.

Primary sclerosing cholangitis (PSC), present in 5% of patients with ulcerative colitis, may be associated with pouchitis after ileal pouch-anal anastomosis. The cumulative frequency of pouchitis in patients with and without PSC who underwent ileal pouch-anal anastomosis for ulcerative colitis was determined. A total of 1097 patients who had an ileal pouch-anal anastomosis for ulcerative colitis, 54 with associated PSC, were studied. Pouchitis was defined by clinical criteria in all patients and by clinical, endoscopic, and histological criteria in 83% of PSC patients and 85% of their matched controls. PSC was defined by clinical, radiological, and pathological findings. One or more episodes of pouchitis occurred in 32% of patients without PSC and 63% of patients with PSC. The cumulative risk of pouchitis at one, two, five, and 10 years after ileal pouch-anal anastomosis was 15.5%, 22.5%, 36%, and 45.5% for the patients without PSC and 22%, 43%, 61%, and 79% for the patients with PSC. In the PSC group, the risk of pouchitis was not related to the severity of liver disease. In conclusion, the strong correlation between PSC and pouchitis suggest a common link in their pathogenesis.

Ileal pouch-anal anastomosis for chronic ulcerative colitis. Long-term results.

The aim of this study was to determine the long-term outcome among 390 patients with ulcerative colitis who underwent ileal J pouch-anal anastomosis and whether patient or operative factors influenced results. The combined operative morbidity rate for the pouch-anal anastomosis and the subsequent closure of the temporary ileostomy was 29% (bowel obstruction, 22%; pelvic sepsis, 5%), with one death due to pulmonary embolus. The probability of a successful outcome at 5 years was 94%. Of the 24 patients who failed (6% of total), 18 did so within 1 year (4%), three during year 2 (1%), three during year 3 (1%), and none thereafter. Stool frequency (7 stools/24 h), the occurrence of pouchitis (14%), and satisfactory daytime continence (94% of patients) remained stable over 4 years after operation, whereas nocturnal fecal spotting decreased (51% of patients to 20%). Women had more spotting than men, whereas patients over 50 years old had more stools per day than those 50 years or younger. In conclusion, ileal pouch-anal anastomosis achieved a reasonable stool frequency and satisfactory continence in patients with ulcerative colitis over the long-term. These results support the ileal pouch-anal anastomosis as a safe, satisfactory alternative to permanent ileostomy.

Results at up to 20 years after ileal pouch–anal anastomosis for chronic ulcerative colitis†

Ileal pouch–anal anastomosis (IPAA) is performed routinely for chronic ulcerative colitis.

Leiomyosarcoma of the small and large bowel

From 1950 through 1974, a total of 108 cases of primary intestinal leiomyosarcoma were seen at the Mayo Clinic. Most of these uncommon tumors occurred in the fifth and sixth decades of life, and more of them in men than in women (2.6:1). There were 73% in the small bowel, 25% in the large bowel, and 2% in the anus. Gastrointestinal bleeding and pain were the two most common signs at presentation, and they led to surgical exploration in all cases where they appeared. By the time surgery was performed, only 48% of the tumors could be resected with hope of cure. Within that group of cases, 50% of the patients survived 5 years, but only 35% survived 10 years, late recurrence being common. The histologic grade of the tumor affected survival strongly. Lack of recognition of the high late recurrence rate probably led to erroneous early optimism in prognosis.

Intraoperative irradiation after palliative surgery for locally recurrent rectal cancer

Background. In patients with locally recurrent rectal cancer, long‐term disease control and survival is uncommon with single‐modality therapy. This report evaluates results achieved at the Mayo Clinic (Rochester, MN) with single‐ or combined‐modality treatment, including intraoperative irradiation.

Functional Outcomes After Ileal Pouch-Anal Anastomosis for Chronic Ulcerative Colitis

OBJECTIVE To assess long-term outcomes after ileal pouch-anal anastomosis (IPAA) for chronic ulcerative colitis (CUC) with specific emphasis on patient sex, childbirth, and age. SUMMARY BACKGROUND DATA Childbirth and the process of aging affect pelvic floor and anal sphincter function independently. Early function after IPAA is good for most patients. Nonetheless, there are concerns about the impact of the aging process as well as pregnancy on long-term functional outcomes after IPAA. METHODS Functional outcomes using a standardized questionnaire were prospectively assessed for each patient on an annual basis. RESULTS Of the 1,454 patients who underwent IPAA for CUC between 1981 and 1994, 1,386 were part of this study. Median age was 32 years. Median length of follow-up was 8 years. Pelvic sepsis was the primary cause of pouch failure irrespective of sex or age. Functional outcomes were comparable between men and women. Eighty-five women who became pregnant after IPAA had pouch function, which was comparable with women who did not have a child. Daytime and nocturnal incontinence affected older patients more frequently than younger ones. Incontinence became more common the longer the follow-up in older patients, but this was not found in younger patients. Poor anal function led to pouch excision in only 3 of 204 older patients. CONCLUSIONS Incontinence rates were significantly higher in older patients after IPAA for CUC compared with younger patients. However, this did not contribute to a greater risk of pouch failure in these older patients. Patient sex and uncomplicated childbirth did not affect long-term functional outcomes.

Long-term results of ileal pouch-anal anastomosis in patients with Crohn's disease

PURPOSE: Ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for most patients with chronic ulcerative colitis. Crohns disease is, however, a contraindication. Because distinction between UC and Crohns disease can be difficult, some patients with Crohns disease inadvertently undergo IPAA. The aim of this study was to determine the long-term outcome of patients with Crohns disease who have undergone IPAA. METHODS: A total of 37 patients (20 men) were studied. Each had undergone mucosectomy with handsewn IPAA (J-pouch, n=35; S-pouch, n=1; W-pouch, n=1). Histologic examination of the resected specimen at time of IPAA showed features of ulcerative colitis (n=22), indeterminate colitis (n=9), or Crohns disease (n=6). The stoma was closed in all patients. RESULTS: A total of 11 of 37 patients developed complex fistulas (pouch-cutaneous (n=6), pouch-vaginal (n=4), or pouch-vesical (n=1). Crohns disease has recurred in the pouch (n=20), anal canal (n=4), pouch and anal canal (n=10), and elsewhere (n=3). After ten years (range, 3–14), the pouch remainsin situin 20 patients in whom frequency of bowel movement is seven times (3–10)/24 hours,in situbut defunctioned in seven patients, and excised in ten patients (failure rate, 45 percent). CONCLUSIONS: Inadvertent IPAA for Crohns disease is associated with a high rate of failure (45 percent) but an acceptable long-term functional result if the pouch can be keptin situ.

The risk of lymph node metastasis in colorectal polyps with invasive adenocarcinoma

One hundred fifty-one patients with colorectal polyps containing invasive adenocarcinoma treated by resection were studied to determine the incidence of lymph node metastasis and whether lymph node metastasis was related to the depth of invasion. Other variables evaluated included size and configuration of the polyp, grade of adenocarcinoma, presence or absence of lymphovascular invasion, and degree of differentiation. In patients with sessile polyps, the incidence of lymph node metastasis was 10 percent. Eighty percent of these lesions had lymphovascular invasion. For pedunculated polyps, the overall incidence of lymph node metastasis was 6 percent. However, there was no incidence of lymph node metastasis when the depth of invasion was limited to the head, neck, and stalk of the polyp (Levels 1, 2, and 3). Only when the depth of invasion reached to the base of the stalk (Level 4) was the risk of lymph node metastasis high (27 percent). The other risk factors were not associated with lymph node metastasis. We concluded that the most significant risk factor for lymph node metastasis in patients with invasive carcinoma in a polyp was invasion into the submucosa of the bowel wall (Level 4).

Curative reoperations for locally recurrent rectal cancer

PURPOSE: Our aims were to determine the morbidity, survival and its influencing factors, and patterns of failure for patients who underwent further surgery with the hope of cure for locally recurrent rectal cancer. METHODS: Between January 1981 and December 1988, 224 patients with a preoperative diagnosis of recurrent rectal cancer underwent additional surgery at Mayo Medical Center in Rochester, Minnesota. Of these, 65 underwent further surgery with the hope of cure,i.e.,no gross/microscopic residual disease at tumor margins after reoperation. Factors assessed included type of original operation, time interval between operation for primary tumor and initial operation for recurrence, symptom status, degree of fixation, types of reoperations for recurrence, and adjuvant therapy. RESULTS: None of the patients died within 30 days of reoperation. Seventeen complications requiring hospitalization and/or surgical procedure were observed in 14 patients. Extended operations (involving partial or complete removal of surrounding organs/structures) required more time to perform, a greater number of transfusions, and a longer hospital stay than more limited operations. Three-year, five-year, and median survival were 57, 34, and 44.7 months, respectively. Survival was greater after curative than after palliative resection (P<0.001). Survival tended to be greater in females (P<0.075) and in patients without pain (P<0.065). Cumulative probability of local failure was 24, 41, and 47 percent at 1, 3, and 5 years, respectively. Cumulative risk of distant metastasis was 30, 51, and 62 percent at 1, 3, and 5 years, respectively. CONCLUSIONS: Our results indicate that complete excision of locally recurrent rectal cancer can provide a significant number of patients with long-term survival and can be accomplished safely in select patients.