Social and sexual function following ileal pouch-anal anastomosis

Ileal pouch-anal anastomosis provides good functional and quality of life outcomes following proctocolectomy: A 33-year single centre experience

BACKGROUND

Restorative proctocolectomy (RP) with ileal pouch-anal anastomosis (IPAA) remains the gold standard for the surgical management of patients with medically refractive mucosal ulcerative colitis. We aimed to identify functional and quality of life (QOL) outcomes in RP and IPAA surgery patients at our institution.

METHODS

A retrospective observational study was performed including all patients who had undergone RP and IPAA between August 1984 and November 2017 at Royal Prince Alfred Hospital (RPAH).

RESULTS

316 consecutive patients were identified, median age 39 (range 5 to 81) years. The median duration of disease was 60 (range 1 to 528) months. Ulcerative colitis was the main preoperative diagnosis with the main RP indication being failure of medical treatment. The median postoperative stay post-IPAA was 11 (range of 5 to 67) days. Pouchitis was the most common late complication (22.1%), bleeding pouch (3.5%) the earliest, with a 6.8% rate of symptomatic anastomotic leak. Visual analogue scale QOL measure (P-value <0.001), St Marks incontinence score (P-value = 0.001) and Cleveland clinic score (P-value = 0.002) all revealed significant improvement in functional outcomes and QOL.

CONCLUSION

QOL and functional outcomes following RP with IPAA in patients at our institution are excellent and comparable to institutions with larger patient numbers.

Psychosocial factors associated with j-pouch surgery for patients with IBD: a scoping review

BACKGROUND

Ulcerative colitis and Crohn's disease are subtypes of inflammatory bowel disease: a chronic condition of unclear etiology characterized by inflammation of the small and large intestine. Inflammatory bowel disease is managed with diet, medications, and surgeries, with the most common surgery, recommended to ulcerative colitis patients being j-pouch surgery.

PURPOSE

To assess the current literature concerning psychosocial factors associated with j-pouch surgery for patients with inflammatory bowel disease.

METHODS

A systematic scoping review of the empirical and grey literature was conducted for original research on j-pouch surgery and psychosocial variables. Eight databases were searched: Medline, PsychInfo, CINAHL, EBM Reviews, ProQuest Dissertations and Theses Global, ResearchGate, Prospero, and PrePubMed.

RESULTS

Thirty-nine articles were identified. Many studies (n = 18) adopted a case-series design, and none examined psychosocial interventions. The most popular psychosocial variables assessed were quality of life (n = 34) and those associated with sexual health and functioning (n = 9).

CONCLUSIONS

Despite being an established surgical procedure, little research has examined the psychosocial implications of j-pouch surgery. As such, clinicians lack a robust understanding of how this procedure affects patients' psychiatric and social status and adaptive abilities. There is a need for high-quality research utilizing validated measures and rigorous design methodologies with control populations.

Inflammatory bowel disease can reduce ovarian reserve function in women: A systematic review and meta-analysis

PURPOSE

We conducted a systematic review and meta-analysis to examine the role of inflammatory bowel disease (IBD) in ovarian reserve functions.

METHODS

The PECO strategy was employed. Women of reproductive age (Population) and with IBD (Exposure) were compared with healthy women of reproductive age (Comparison) to evaluate the ovarian reserve function (Outcome). Two reviewers searched three databases as well as relevant gray literature. After following the PRISMA 2020 guidelines, RevMan 5.0 software and Newcastle-Ottawa Scale (NOS) scoring were used to analyze and summarize the data included in the studies. The protocol was registered on PROSPERO (CRD42021267804).

RESULTS

The search yielded 367 studies, out of which 13 were selected for full-text evaluation, and finally, seven studies were included in our research. An analysis of ovarian reserve function in IBD women of reproductive age and healthy women revealed that the ovarian reserve function was lower in IBD women of reproductive age than in healthy women (P < .01, I2 = 81%); the ovarian reserve function was significantly lower in women with IBD in remission than in healthy women (P < .01, I2 = 0%), and ovarian reserve function was lower in IBD women of reproductive age taking thalidomide than in healthy women (P < .01, I2 = 18%).

CONCLUSION

IBD could reduce ovarian reserve function in women of reproductive age, and patients should plan for conception as soon as possible under permissible conditions.

Examining the impact of marketing techniques on the prescription behavior of physicians with ethical ideology as a moderator

Purpose

This research paper aims to investigate the impact of pharmaceutical marketing on the prescription behavior of physicians. It further examines whether the use of various promotional techniques including advertisements, sales promotions, personal selling and direct marketing by pharmaceutical companies influences the prescription behavior of doctors. Based on the increasing ethical concerns regarding the promotion of specific drugs for personal gains, the research also investigated the moderating role of ethical ideology in the above relationship.

Design/methodology/approach

To accomplish the research goals, quantitative research methods were used. Using the online questionnaire, data were collected from 93 doctors working in government and private hospitals in Pakistan, and structural equation modeling technique was used to analyze the impact of pharmaceutical marketing techniques on the prescription decisions of physicians.

Findings

The findings suggested that marketing strategies of pharmaceutical companies positively influences the prescription behavior of doctors. Further, physicians having weak ethical standards are likely to be strongly influenced by the marketing and promotional practices of companies.

Practical implications

The research is pivotal in understanding the perspective of doctors and the ethical considerations that need to be addressed while devising the marketing campaigns by pharmaceutical companies. Further, these findings provide important implications regarding the essential linkage between ethical values and the development of right marketing tools.

Originality/value

To the best of the authors’ knowledge, this research is one of the first few to empirically develop and test the role of moral values followed by physicians when they take prescription decisions. Based on the findings, future researchers are encouraged to further investigate the need of setting boundaries for pharmaceutical companies and restricting their usage regarding the promotional tactics.

Sexual Dysfunction in Female Patients with Inflammatory Bowel Disease: An Overview

Sexual dysfunction is common among females with inflammatory bowel disease and may result in issues involving intimacy, sexual activity, and satisfaction, as well both the formation and preservation of personal relationships. Risk factors for sexual dysfunction include select surgical interventions, medications, mental illnesses, and IBD-related intestinal and extraintestinal comorbidities. In addition, certain demographic factors such as age, disease type and activity may influence the severity of sexual dysfunction. Evaluation of sexual dysfunction may include the use of validated sexual functioning questionnaires, a brief mental health assessment, initial inquiry into vulvovaginal or perineal symptoms, and a gynecologic and GI-focused physical exam. An interdisciplinary care team involving IBD specialists, obstetrician-gynecologists, pelvic floor physical therapists, and primary care physicians may be best suited to provide optimal care and treatment recommendations for patients with sexual dysfunction. Options for management often include pelvic floor physical therapy, biofeedback, and mental health support. Further research is necessary to delineate the impact of IBD activity on sexual dysfunction, to determine if health outcome differences exist depending on surgical approaches utilized during J-pouch operations, and finally to evaluate the care and perceptions of patients with IBD who identify as sexual and gender minorities.

Work productivity loss is determined by fatigue and reduced quality of life in employed inflammatory bowel disease patients: a prospective multicentre cohort study

OBJECTIVE

Inflammatory bowel disease (IBD) patients experience problems at work resulting in work productivity loss driving indirect healthcare costs. We aimed to find determinants for work productivity loss in employed IBD patients while correcting for disease severity according to prior and active maintenance treatment.

METHODS

In this longitudinal multicentre cohort study, 510 employed IBD patients completed online questionnaires during 18 months follow-up. Work productivity, fatigue and health-related quality of life (HRQL) were measured using the Work Productivity and Activity Impairment questionnaire, the Multidimensional Fatigue Inventory (score 20-100) and Short-Inflammatory Bowel Disease Questionnaire (score 10-70). Linear mixed model analyses including random, repeated and fixed effects were performed.

RESULTS

Fatigue (β 0.22; 95% CI, 0.12-0.32) and reduced HRQL (β -1.15; 95% CI, -1.35 to -0.95) were the strongest determinants for work productivity loss in employed IBD patients. Clinical disease activity (β 9.50, 95% CI 6.48-12.51) and corticosteroid use (β 10.09, 95% CI 5.25-15.84) were associated with work productivity loss in the total IBD group and ulcerative colitis subgroup, but not in Crohn's disease patients. History of IBD-related surgery (β 9.41; 95% CI, 2.62-16.20) and vedolizumab use (β 12.74; 95% CI, 3.63-21.86) were significantly associated with work productivity loss in the ulcerative colitis subgroup.

CONCLUSIONS

Fatigue and reduced HRQL were the strongest determinants for work productivity loss in employed IBD patients while correcting for disease severity and activity. These results underline the importance of monitoring fatigue and HRQL in routine care to reduce work productivity loss and indirect costs.

Sexual activity in patients after proctocolectomy with ileal pouch-anal anastomosis

&lt;b&gt;Introduction:&lt;/b&gt; Proctocolectomy with ileal pouch-anal anastomosis is the gold standard in the surgical treatment of patients with ulcerative colitis, familial adenomatous polyposis and other colorectal diseases requiring colectomy. The treatment consists in removing the large intestine and creating an intestinal reservoir from the last ileum loop and then anastomosing the intestinal reservoir with the anal canal. Like any surgical procedure, RPC-IPAA also carries the risk of complications, both early and late. Late postoperative complications include sexual dysfunction. &lt;br&gt;&lt;b&gt;Aim:&lt;/b&gt; The main goal of the following work is to assess the quality of life and sexual activity in patients having undergone the RPC-IPAA procedure at the General and Colorectal Surgery Clinic. &lt;br&gt;&lt;b&gt;Material and methods:&lt;/b&gt; The study group consisted of patients aged 19-79 who had been subjected to RPC-IPAA procedures at the General and Colorectal Surgery Clinic in years 2010-2019. The study was conducted on the basis of a survey consisting of 50 questions about the social and mental condition, medical history and previous treatment as well as the quality of sexual life before and after surgery. The scale used for the assessment of the quality of sex life consisted of 5 grades: very low, low, medium, high, very high. Thirty subjects (21 men and 9 women) took part in the survey. Ulcerative colitis (86.6%) was the most common reason for qualification for restorative proctectomy among the examined patients; less common reasons included familial adenomatous polyposis (13.3%) and synchronous colorectal cancer (3.3%). A vast majority of the surgeries had been performed after 10 years' duration of ulcerative colitis, and the intestinal reservoir had been functioning for over a year at the time of the examination. In addition, the effect of taking steroids and the impact of early postoperative complications on the quality of sex life of patients was assessed. &lt;br&gt;&lt;b&gt;Results:&lt;/b&gt; High or very high sexual activity before surgery was reported by 46% of patients whereas low or very low quality was reported by 13%. The rest of the responders assessed their pre-operative sexual activity as average. After surgery, 23% of patients rated their sexual activity as high or very high while 36.6% of patients rated it as low or very low (P = 0.07). It was also noted that taking corticosteroids before surgery decreased the quality of sex life after surgery (P = 0.07 for activity, P = 0.04 for quality). None of the women surveyed used artificial moisturizing of intimate places during sex. Only 1 person stated that they started using artificial moisturization of intimate places after the procedure (P = 0.5). None of the men surveyed had used pharmacological agents to help them obtain an erection before surgery while as many as 33% of responders reported the need for their use after surgery (P = 0.008). Other postoperative sexual dysfunctions were also registered, such as dyspareunia (13.3%), sensory disorder within the intimate region, fecal incontinence, and urinary incontinence. &lt;br&gt;&lt;b&gt;Conclusions:&lt;/b&gt; To sum up, sexual activity and quality of sexual life deteriorated after RPC-IPAA in our patients.

Modeling epidemic spreading through public transit using time-varying encounter network

Passenger contact in public transit (PT) networks can be a key mediate in the spreading of infectious diseases. This paper proposes a time-varying weighted PT encounter network to model the spreading of infectious diseases through the PT systems. Social activity contacts at both local and global levels are also considered. We select the epidemiological characteristics of coronavirus disease 2019 (COVID-19) as a case study along with smart card data from Singapore to illustrate the model at the metropolitan level. A scalable and lightweight theoretical framework is derived to capture the time-varying and heterogeneous network structures, which enables to solve the problem at the whole population level with low computational costs. Different control policies from both the public health side and the transportation side are evaluated. We find that people's preventative behavior is one of the most effective measures to control the spreading of epidemics. From the transportation side, partial closure of bus routes helps to slow down but cannot fully contain the spreading of epidemics. Identifying "influential passengers" using the smart card data and isolating them at an early stage can also effectively reduce the epidemic spreading.

[Comparative assesement of postoperative quality of life in patients with ulcerative colitis]

OBJECTIVE

To compare quality of life in patients undergoing proctocolectomy with ileal pouch procedure and ileostomy taking into account sexual function.

MATERIAL AND METHODS

The comparative observational study included 138 patients with ulcerative colitis for the period 2013-2018. All patients underwent surgery with one- or two-stage formation of pelvic pouch (n=76) or ileostomy (n=62). Validated questionnaires SF-36, The International Index of Erectile Function (IIEF), Female Sexual Function Index (FSFI) were used in the study.

RESULTS

Patients with pelvic pouch were significantly younger than patients with terminal ileostomy (33.7±10.9 and 44.6±14.9 years, respectively, p<0.0001). The majority of the parameters of SF-36 questionnaire were similar in both groups. Pain syndrome intensity was the only sign demonstrating the advantage of ileostomy over pelvic pouch. However, regression analysis did not confirm the effect of surgical technique on pain severity. Orgasmic function was significantly better in men with pelvic pouch compared to ileostomy. Other indicators of sexual function were similar. According to FSFI questionnaire, women with pelvic pouch also showed significantly better results than patients with permanent ileostomy. However, multivariate regression analysis revealed no significant effect of surgical technique on sexual function in men and women. At the same time, significant negative correlation between IIEF and FSFI scores and age was revealed.

CONCLUSION

No significant influence of surgical technique on postoperative QOL was observed in patients with ulcerative colitis. Better sexual function in men and women with pelvic pouch are due to younger age rather type of surgery.

The impact of inflammatory bowel disease on sexual health in men: A scoping review

AIMS AND OBJECTIVES

To review the literature on the impact of inflammatory bowel disease on the sexual health of men and make recommendations for nursing practice and research.

BACKGROUND

Inflammatory bowel disease is a chronic condition of the gastrointestinal tract, causing symptoms that may impact upon sexual health. Specialist nurses are well positioned to assess and manage sexual health, but there is a lack of clinical guidance, especially in relation to men.

DESIGN

A systematic scoping review following the Arksey and O'Malley (International Journal of Social Research Methodology, 8, 2005, 19) framework reported in line with the PRISMA-ScR checklist (Tricco et al., Annals of Internal Medicine, 169, 2018, 467).

METHODS

OVID MEDLINE ALL [R], OVID EMBASE [R], OVID PsychINFO, EBSCO CINAHL Complete, The Cochrane Library and ProQuest were searched. Inclusion and exclusion criteria were applied independently by two reviewers. Data were extracted, charted and summarised from eligible studies.

RESULTS

Thirty-one studies met the inclusion criteria. These were synthesised under three categories: mediators, moderators and descriptors of sexual health. Depression, disease activity and surgery were the most commonly cited disease-related factors to affect sexual health in men. The most commonly used assessment tool was The International Index of Erectile Function. Descriptors of function included frequency of intercourse, libido and the ability to maintain a desired sexual role.

CONCLUSIONS

The effect of inflammatory bowel disease on sexual health in men involves a complex interaction of physical and psychosocial factors. Researchers must explore areas outside of erectile function to understand how the disease impacts sexuality, sexual well-being and masculinity. This can be achieved through qualitative exploration of patient, partner and health professional experiences.

RELEVANCE TO CLINICAL PRACTICE

A holistic nursing assessment of men with inflammatory bowel disease should include sexual health. Developing understanding of how the disease influences sexual interaction and expression will facilitate support that is relevant, accessible and of value to men living with the disease.

Gastro-intestinal surgery and fertility

In France, 10 to 15% of couples in the overall population have a fertility problem. Preservation of sexual and reproductive function should be a major concern for all patients capable of procreation who undergo treatment for gastro-intestinal disease. The gastro-intestinal diseases most often responsible for fertility disorders include chronic inflammatory diseases, intestinal cancer and hereditary diseases, such as the Lynch syndrome and familial adenomatous polyposis. Obesity is responsible for a 20% loss of fertility but the effects of bariatric surgery on fertility are controversial. Nonetheless, in the light of progress in surgical techniques and better knowledge of gastro-intestinal disease the negative impact of surgery on fertility warrants attention. Effectively, fertility can be preserved after certain major gastro-intestinal operations such as cytoreductive surgery with intraperitoneal chemotherapy, total coloprotectomy with ileo-anal anastomosis and rectosigmoid resection, as long as the patient's age permits and resection of the reproductive organs is not necessary.

Sexual and reproductive issues and inflammatory bowel disease: a neglected topic in men

There has been considerable literature on sexual issues in women with inflammatory bowel disease (IBD), but relatively little attention has been paid to these aspects in men. To review the available literature and to provide the best management of sexual and reproductive issues in male patients with IBD. The scientific literature on sexual and reproductive issues in men with IBD was reviewed. Several factors, including surgical and medication treatments, disease activity, lifestyle, and psychological factors, may play a role in the development of infertility and sexual dysfunction and may negatively impact pregnancy outcomes. Proctocolectomy with ileal pouch-anal anastomosis increases the risk of erectile and ejaculatory dysfunction by up to 26%. A treatment with sildenafil can be effective. Sperm banking should be advised to young men with IBD before surgery. Both sulfasalazine and methotrexate may be responsible for reversible sexual dysfunction and infertility. Furthermore, sulfasalazine should be switched to mesalazine at least 4 months before conception because of a higher risk of congenital malformations in pregnancies fathered by men treated with this drug. Psychotropic drugs, frequently used in IBD, may cause sexual dysfunction up to 80%. Last but not the least, voluntary childlessness occurs frequently, mainly because of concerns about medication safety in pregnancy and fear of transmitting disease. Accurate counseling, and where necessary, psychological support can decrease any misperceptions and fears. Close collaboration between the gastroenterologist and the patient is recommended for the best management of these relevant, neglected aspects in men with IBD.

Managing inflammatory bowel disease in pregnancy: current perspectives

Inflammatory bowel disease (IBD) affects many women of childbearing age. The course of IBD is closely related to pregnancy outcomes with poorly controlled IBD increasing the risk of prematurity, low weight for gestation, and fetal loss. As such, women with IBD face complex decision making weighing the risks of active disease versus those of medical treatments. This review summarizes the current evidence regarding the safety and efficacy of IBD treatments during pregnancy and lactation aiming to provide up-to-date guidance for clinicians. Over 50% of women have poor IBD- and pregnancy-related knowledge, which is associated with views contrary to medical evidence and voluntary childlessness. This review highlights the effects of poor patient knowledge and critically evaluates interventions for improving patient knowledge and outcomes.

What Factors Might Drive Voluntary Childlessness (VC) in Women with IBD? Does IBD-specific Pregnancy-related Knowledge Matter?

INTRODUCTION

Inflammatory Bowel Disease (IBD) affects many women of childbearing age, and rates of voluntary childlessness (VC) exceed those of the general population by far. The factors surrounding VC remain incompletely understood.

METHODS

Female members of the patient organisation Crohn's and Colitis UK aged 18-45 years were invited to complete an online questionnaire collecting data on demographics, disease characteristics, Crohn's and Colitis pregnancy-specific disease-related knowledge (CCPKnow), and childlessness status.

RESULTS

A total of 1324 women (mean age 33 years) completed the survey: 776 (59%) were diagnosed with Crohn's disease (CD), 496 (38%) with ulcerative colitis (UC) and 4% with inflammatory bowel disease-unclassified (IBD-U); 40% had children (14% pre-diagnosis (I); 26% post-diagnosis (II)), 36% planned to have children at some stage (III), 7% reported fertility problems (IV), and 17% were classified as voluntarily childless (VC). VC was associated with poorer CCPKnow scores [5.98 vs. 7.47 in (III); p < 0.001], older age [35 years old vs. 28 years old in (II); p < 0.001], unemployment (9.7% VC; p < 0.001), being single (34.5% VC; p < 0.001) not seeking medical advice (p < 0.001), and diagnosis of CD (19.3% vs. 13.9% UC; p = 0.015). Women with VC had more hospital admissions [mean 2.85 vs. 2.17 (III); p = 0.03] and surgical interventions [mean 1.27 vs. 0.65 (III); p < 0.001]

CONCLUSION

The aetiology of VC in women with IBD is multifactorial. Women's choice regarding children appears related to disease burden. VC is also associated with poor knowledge (CCPKnow), and women may stay childless unnecessarily. Patient education programmes could help to reduce the rate of VC in women with IBD, through correcting misconceptions and alleviating patient concerns.

Gender Issues in Inflammatory Bowel Disease

Crohn's disease and ulcerative colitis are two chronic inflammatory conditions involving the gastrointestinal tract. While many aspects of the management of these diseases are identical for all patients, there are some issues specific to women that are not necessarily part of routine care. Certain gender-specific issues such as menses, fertility, pregnancy and menopause are often overlooked and mismanaged. Women have different psychologic concerns compared with men in regard to their self-image and impact of disease. Healthcare providers, regardless of their primary focus, should be aware of these differences and be familiar with general information specific to women.

Optimizing the Care and Health of Women with Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) including both ulcerative colitis and Crohn's disease is increasing worldwide. Although diagnosis is equally found in men and women, the chronicity of IBD poses a unique impact on the milestones of a woman's life. As the gastroenterologist becomes increasingly important in the health maintenance of patients with IBD, this review stresses the unique gender issues in women with IBD related to menstruation, cervical cancer, sexual health, contraception, and menopause that may affect the course of disease, treatment decisions, and quality of life.

Getting personal: a review of sexual functioning, body image, and their impact on quality of life in patients with inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD), which includes Crohn's disease and ulcerative colitis, is a chronic relapsing disorder associated with distressing physical and psychological symptoms. Many patients with IBD have impaired quality of life. Sexual functioning and body image are rated high among concerns of patients with IBD and may impact quality of life. A better understanding of the roles of sexual functioning and body image in quality of life for patients with IBD is needed because improvement in quality of life is a primary therapeutic goal. The aim of this review was to summarize the current literature on sexual functioning and body image in patients with IBD, emphasizing their impact on quality of life.

METHODS

An electronic search of the literature was conducted using the PubMed, PsycINFO, and Cochrane databases. Key phrases included: "Ulcerative Colitis/Crohn's disease/Inflammatory Bowel Disease and sexual function," and "Ulcerative Colitis/Crohn's disease/Inflammatory Bowel Disease and body image." The search produced 1284 citations. We identified 56 studies, which were conducted from 1990 through April 2014, written in English, and included at least 10 adults with IBD.

CONCLUSIONS

Few studies have tested directly the association between quality of life and sexual functioning and body image among patients with IBD. Results preliminarily suggest a positive relationship between quality of life and sexual functioning and body image postoperatively among patients with IBD. Future studies comprised of patients who have not had surgery are necessary to better understand the relationship between sexual functioning, body image, and quality of life in patients with active and inactive IBD.

Male issues of the ileal pouch

: Restorative proctocolectomy with ileal pouch-anal anastomosis is the standard surgical treatment modality for patients with ulcerative colitis who require colectomy. There are special issues related to male gender. We performed systemic literature review on the topic, incorporating the experience in our specialized Center for Ileal Pouch Disorders, and provide recommendations for the identification and management for the gender-specific issues in male patients with ileal pouches. Chronic pouchitis, particularly ischemic pouchitis, anastomotic leak, and presacral sinus are more common in male patients than their female counterparts. Sexual dysfunction can occur after pouch surgery, particularly in those with pouch failure. Diagnosis and management of benign and malignant prostate diseases can be challenging due to the altered pelvic anatomy from the surgery. Digital rectal examination for prostate cancer screening is not reliable. Transpouch biopsy of prostate may lead to pouch fistula or abscess. Pelvic radiation therapy may have an adverse impact on the pouch function. In conclusion, sexual dysfunction and enlarged prostate can occur in patients with the ileal pouch. The measurement of serum prostate-specific antigen is a preferred method for the screening of prostate cancer. If biopsy of the prostate is needed, the perineal route is recommended. The risk for pouch dysfunction and the benefit for oncologic survival of pelvic radiation for prostate cancer should be carefully balanced.

The second European evidenced-based consensus on reproduction and pregnancy in inflammatory bowel disease

Trying to conceive and being pregnant is an emotional period for those involved. In the majority of patients suffering from inflammatory bowel disease, maintenance therapy is required during pregnancy to control the disease, and disease control might necessitate introduction of new drugs during a vulnerable period. In this updated consensus on the reproduction and pregnancy in inflammatory bowel disease reproductive issues including fertility, the safety of drugs during pregnancy and lactation are discussed.

Women's health issues after ileal pouch surgery

: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for patients with ulcerative colitis and familial polyposis who require colectomy. This surgical intervention allows for resection of colon, while offering intestinal continuity with fecal continence, discontinuation of most medications related to ulcerative colitis and reduction in the risk of colitis-associated neoplasia. As a proportion of these patients are women of childbearing age, it is important to understand the impact on reproductive health and function. Although limited data exist, restorative proctocolectomy/IPAA does not seem to adversely affect menstrual function. In general, sexual function is reported to improve postsurgery with the ability to achieve orgasm unaltered. However, dyspareunia is commonly reported post restoratively. Of concern, there are data to suggest that fertility is decreased post-IPAA. The reasons stated are pelvic adhesions and obstruction of fallopian tubes. Laparoscopic approach may improve fertility outcomes by reducing postoperative adhesions as compared with the open approach. Once achieved, pregnancy in patients with IPAA is characterized by a transient increase in stool frequency that resolves postdelivery. Whether vaginal delivery or cesarean section is preferred route of delivery in these patients is still controversial. But commonly cesarean section is advocated for patients' post-IPAA to prevent anal sphincter injury and long-term effects on pouch function. All of these issues should be included in the discussion with women who are contemplating IPAA, so they are well aware of them before deciding on the best management plan.

Sick leave and disability pension in inflammatory bowel disease: a systematic review

BACKGROUND & AIMS

Inflammatory bowel disease has considerable effects on work-related outcomes and leads to high societal costs due to sick leave and disability pension. The aims of this study were to systematically review evidence on work-related outcomes that are relevant to productivity losses and to evaluate whether medical or surgical interventions have a positive impact on patients' work ability.

METHODS

A systematic literature search in PubMed was conducted in June 2013. Abstracts were screened by two independent reviewers, and full-text articles describing the frequency of work-related outcomes were retrieved. Two independent reviewers extracted data according to the PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses. Findings were organized by study design (non-interventional/interventional). Non-interventional studies were structured according to whether they presented data in comparison to control groups or not and interventional studies were summarized according to type of intervention.

RESULTS

This review included 30 non-interventional (15 with comparison groups and 15 without comparison group) and 17 interventional studies (9 surgical and 8 medical). The majority of the studies reported a high burden of work-related outcomes among inflammatory bowel disease patients regardless of the methodology used. While biologic agents showed positive effect on work absenteeism and presenteeism in randomized clinical trials, the impact of surgical interventions needs further evaluation.

CONCLUSIONS

Inflammatory bowel disease patients experience a high burden in work-related outcomes. Additional data on productivity losses and the long-term impact of interventions is needed to help inform decision-makers about treatment options and their benefits in reducing productivity losses in inflammatory bowel disease patients.

Review article: strategies for the management of chronic unremitting ulcerative colitis

BACKGROUND

Chronic active ulcerative colitis (UC) is associated with significant morbidity, loss of productivity, increased colorectal cancer risk and cost. Up to 18% of patients suffer chronic active disease, with 30% requiring colectomy at 10 years. The management remains challenging given the relatively few clinical trials in this area.

AIM

To summarise the evidence regarding optimal management strategies for patients with chronic active UC of differing disease extents and degrees of treatment refractoriness.

METHOD

A literature search using the PubMed and Medline databases was performed. No time limit was set on article publication for inclusion.

RESULTS

The principles of management should focus on confirming disease activity, exclusion of alternative diagnoses, adherence and treatment escalation. Infliximab and topical tacrolimus are options in refractory proctitis, although the evidence for these therapies is limited. Both infliximab and adalimumab are effective in corticosteroid-refractory disease, although the proportions of patients achieving corticosteroid-free remission remain modest (24% at 30 weeks and 16.9% at 8 weeks respectively). Alternatives include ciclosporin and tacrolimus, and possibly methotrexate. Colectomy often leads to an improved quality of life; medical strategies unlikely to provide durable corticosteroid-free remission should not be pursued.

CONCLUSIONS

No current pharmacological treatment delivers mucosal healing in the majority of patients. Newer treatments such as vedolizumab and tofacitinib may represent valuable future therapies. Available medical options should be discussed with patients at every step of their management, with an honest appraisal of the evidence. Surgery should always be considered in patients with chronic refractory disease of any extent.

Patients with ulcerative colitis miss more days of work than the general population, even following colectomy

BACKGROUND & AIMS

It is unclear whether colectomy restores the ability of patients with ulcerative colitis (UC) to work to precolectomy levels. We estimated the burden of sick leave and disability pension in a population-based cohort of patients with UC and the effects of colectomy.

METHODS

We performed a register-based cohort study using the Swedish National Patient Register and identified working-age patients with UC in 2005 (n = 19,714) and patients who underwent colectomies between 1998 and 2002 (n = 807). Sick leave and disability pension data were retrieved from Statistics Sweden (1995-2005). Data from each patient in the study were compared with those from 5 age-, sex-, education-, and county-matched individuals from the general population.

RESULTS

In 2005, 15% of patients with prevalent UC received a disability pension, compared with 11% of the general population, and 21% vs 13% had ≥1 sick leave episode (P < .001 for each comparison). The annual median work days lost was 0 in both groups, but patients with UC had higher mean (65 vs 45 days; difference, 20; 95% confidence interval [CI], 18-22 days) and 75th percentile work days lost (37 vs 0 days; difference, 37; 95% CI, 36-38 days). Among patients who underwent colectomies, annual days lost increased from a mean of 40 (median, 0) days 3 years before surgery to 141 (median, 99) days during the year of surgery (P < .001). The number then decreased to a mean of 85 days 3 years after surgery (median, 0). The corresponding 75th percentile days were 17, 207, and 130, respectively. Three years after colectomy, 12% did not work at all compared with 7.2% of the general population (risk difference, 5.2%; 95% CI, 2.7%-7.7%) and compared with 5.9% 3 years before colectomy (P < .001).

CONCLUSIONS

Patients with UC miss more work days than the general population in Sweden. Although most patients had no registered work loss 3 years after colectomy, work loss was not restored to presurgery or general population levels in the group that underwent colectomy during several years of follow-up.

Serum anti-Müllerian hormone levels are lower in reproductive-age women with Crohn's disease compared to healthy control women

BACKGROUND AND AIM

Crohn's disease (CD) decreases fertility both directly, by inducing inflammation in the fallopian tubes and ovaries, and indirectly, through the surgical interventions and tubal adhesions associated with disease treatment. Anti-müllerian hormone (AMH) is a reliable indicator of ovarian reserve in women. We aimed to compare serum AMH levels between reproductive-age women with CD and healthy controls.

METHODS

Serum AMH levels were measured by ELISA in 35 women with CD and 35 age-matched healthy women controls.

RESULTS

CD patients and controls were similar in terms of age, height, weight and BMI. Mean CD duration was 60 months. CRP, ESR and leukocyte counts were significantly higher in CD patients compared to the controls (p<0.001, p=0.004 and p=0.04, respectively). AMH levels in CD patients (1.02 ± 0.72) were significantly lower compared to the controls (1.89 ± 1.80) (p = 0.009). Serum AMH levels in CD patients with active disease (0.33 ± 0.25) were significantly lower compared to CD patients who were in remission (1.53 ± 0.49) (p = 0.001). Serum AMH levels were similar in CD patients with a disease duration of less than 5 years (17 patients) and CD patients with a disease duration of greater than 5 years (18 patients) (p = 0.8). In CD patients, a negative correlation between CDAI and serum AMH levels was found (r = -0.718, p < 0.001). Serum AMH levels were similar in CD patients who had (6 patients) and had not undergone (29 patients) surgical treatment (p = 0.2).

CONCLUSION

Serum AMH levels of reproductive-age women with CD were significantly lower compared to the controls. CDAI and AMH are inversely correlated.

Sexual activity after ileal pouch-anal anastomosis in Japanese patients with ulcerative colitis

PURPOSE

The aim of this study was to evaluate the sexual activity after restorative proctocolectomy with ileal J-pouch-anal anastomosis (ileoanal anastomosis) in Japanese patients with ulcerative colitis.

METHODS

Sixty-one patients who had undergone ileoanal anastomosis and were followed for at least 6 months after surgery were randomly selected. Their quality of life was assessed using the Japanese version of the Inflammatory Bowel Disease Questionnaire. Scores of three or less for the item "Sex life" were predetermined to represent poor sexual activity. The medical staff then asked them the reasons for this using a non-structured interview and open-ended questions.

RESULTS

Overall, 19 patients reported poor sexual activity. There was a significant difference in the scores for "Social functions" other than Sex life between individuals with poor and good sexual activities (21.6 ± 4.6 vs. 24.1 ± 4.2, P = 0.016). Ileoanal anastomosis after the age of 40 (OR 22, P = 0.02) and a total preoperative corticosteroid dose ≥15 g (OR 7.4, P = 0.04) were significant risk factors for poor sexual activity after ileoanal anastomosis.

CONCLUSION

Our results suggest that ileoanal anastomosis results in relatively poor sexual activity, which was associated with other social functions, older age and a higher dose of corticosteroids administered to Japanese patients with ulcerative colitis.

Study of sexual, urinary, and fecal function in females following restorative proctocolectomy

BACKGROUND

The aim was to investigate quality of life, sexual, fecal, and urinary function in females undergoing restorative proctocolectomy (RPC).

METHODS

A prospective case-control study was performed in two tertiary centers. Controls were females with ulcerative colitis, without a stoma or RPC. Validated questionnaires (SF-36, Female sexual function index, King's questionnaire, and the Wexner scale) were administered in the outpatient setting. Pearson chi(2), t-test, and Mann-Whitney U-tests were used to assess significance.

RESULTS

A total of 255 females were identified and 49% (n = 124) recruited. In all, 109 patients fulfilled the inclusion criteria: 55 (50.5%) inflammatory bowel disease (IBD); 54 (49.5%) RPC. The mean age of RPC patients was 41.8 years (± 12.7 SD) vs. 43.8 years (± 15.8) for IBD (P = 0.491). RPC females with urinary symptoms (urgency, frequency, or incontinence) were 10 years younger than IBD (RPC mean age 37.6 ± 7.3 years vs. IBD 47.4 ± 13.5; P = 0.044). Urgency in fecal function was experienced by more IBD patients (IBD 75.0% vs. RPC 47.9%; P = 0.006), although RPC patients had increased day (P < 0.001) and night bowel frequency (P < 0.001) and were more likely to experience night seepage (P = 0.001). RPC females who had a vaginal delivery (VD) were more likely to have day seepage (P = 0.046) and require pads (P = 0.026) than RPC females who had not undergone VD. There was no significant difference in sexual function.

CONCLUSIONS

RPC may adversely impact urinary function in female patients over time. Bowel frequency, seepage, and pad usage are increased following RPC and function may be worse following VD. RPC does not adversely affect overall sexual function.

A comprehensive review of inflammatory bowel disease focusing on surgical management

The two main diseases of inflammatory bowel disease are Crohn's disease and ulcerative colitis. The pathogenesis of inflammatory disease is that abnormal intestinal inflammations occur in genetically susceptible individuals according to various environmental factors. The consequent process results in inflammatory bowel disease. Medical treatment consists of the induction of remission in the acute phase of the disease and the maintenance of remission. Patients with Crohn's disease finally need surgical treatment in 70% of the cases. The main surgical options for Crohn's disease are divided into two surgical procedures. The first is strictureplasty, which can prevent short bowel syndrome. The second is resection of the involved intestinal segment. Simultaneous medico-surgical treatment can be a good treatment strategy. Ulcerative colitis is a diffuse nonspecific inflammatory disease that involves the colon and the rectum. Patients with ulcerative colitis need surgical treatment in 30% of the cases despite proper medical treatment. The reasons for surgical treatment are various, from life-threatening complications to growth retardation. The total proctocolectomy (TPC) with an ileal pouch anal anastomosis (IPAA) is the most common procedure for the surgical treatment of ulcerative colitis. Medical treatment for ulcerative colitis after a TPC with an IPAA is usually not necessary.

Pregnancy related issues in inflammatory bowel disease: evidence base and patients' perspective

Inflammatory bowel disease (IBD) affects women of childbearing age and can influence fertility, pregnancy and decisions regarding breastfeeding. Women with IBD need to consider the possible course of disease during pregnancy, the benefits and risks associated with medications required for disease management during pregnancy and breastfeeding and the effects of mode of delivery on their disease. When indicated, aminosalicylates and thiopurines can be safely used during pregnancy. Infliximab and Adalimumab are considered probably safe during the first two trimesters. During the third trimester the placenta can be crossed and caution should be applied. Methotrexate is associated with severe teratogenicity due to its folate antagonism and is strictly contraindicated. Women with IBD tend to deliver earlier than healthy women, but can have a vaginal delivery in most cases. Caesarean sections are generally recommended for women with active perianal disease or after ileo-anal pouch surgery.While the impact of disease activity and medication has been addressed in several studies, there are minimal studies evaluating patients' perspective on these issues. Women's attitudes may influence their decision to have children and can positively or negatively influence the chance of conceiving, and their beliefs regarding therapies may impact on the course of their disease during pregnancy and/or breastfeeding. This review article outlines the impact of IBD and its treatment on pregnancy, and examines the available data on patients' views on this subject.

Surgical treatment of ulcerative colitis in the biologic therapy era

Recently introduced in the treatment algorithms and guidelines for the treatment of ulcerative colitis, biological therapy is an effective treatment option for patients with an acute severe flare not responsive to conventional treatments and for patients with steroid dependent disease. The reduction in hospitalization and surgical intervention for patients affected by ulcerative colitis after the introduction of biologic treatment remains to be proven. Furthermore, these agents seem to be associated with increase in cost of treatment and risk for serious postoperative complications. Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice in ulcerative colitis patients. Surgery is traditionally recommended as salvage therapy when medical management fails, and, despite advances in medical therapy, colectomy rates remain unchanged between 20% and 30%. To overcome the reported increase in postoperative complications in patients on biologic therapies, several surgical strategies have been developed to maintain long-term pouch failure rate around 10%, as previously reported. Surgical staging along with the development of minimally invasive surgery are among the most promising advances in this field.

Sexual function after failed ileal pouch-anal anastomosis

BACKGROUND AND AIMS

Failure of ileal pouch-anal anastomosis (IPAA) occurs in around 10% of the patients. Compared to patients with functioning pouches, health related quality of life is deteriorated after failure. Sexual function in patients with pouch failure is however poorly studied. The aim was to study sexual function in patients with pelvic pouch failure; patients with functioning pouches were used as controls. The hypothesis was that patients with pouch failure have worse sexual function.

METHODS

36 patients with pouch failure were compared with 72 age and sex-matched controls with ulcerative colitis and functioning pouches. The patients answered a set of questionnaires concerning sexual function (Female Sexual Function Index [FSFI] and International Index of Erectile Function [IIEF]), body image (BIS-scale) and health-related quality of life (SF-36).

RESULTS

Both women and men with pouch failure scored lower than controls in the FSFI and IIEF questionnaires. However, none of the observations were statistically significant. The scores in the failure group (for both sexes) were below the cut-off level for sexual dysfunction. Scores for the BIS instrument were significantly lower for both sexes in the failure group. Women and men in the failure group scored lower than the controls in all domains of the SF-36, however statistically significant only for the social function domain in men.

CONCLUSIONS

The hypothesis, that a failed IPAA is associated with worse sexual function, was not confirmed. Compared to patients with functioning pouches, patients with pouch failure have inferior body image.

Female sexual function after abdominoperineal resection for squamous cell carcinoma of the anus and the specific influence of colpectomy and vertical rectus abdominis myocutaneous flap

AIM

Abdominoperineal resection (APR) is the only curative treatment for recurrent or persisting squamous cell carcinoma of the anus after radiochemotherapy. A vertical rectus abdominis myocutaneous (VRAM) flap reduces perineal morbidity. The sexual life (SL) of women after APR is unknown. Aims of this study were to evaluate SF of women after APR.

METHOD

47 women alive after APR performed between 1996 and 2007 were included. SL was evaluated using the female sexual function index (FSFI) score.

RESULTS

29 (62%) women answered the questionnaire: 15 (52%) had a VRAM and 16 (55%) a colpectomy. Among the 21 patients with SL before surgery, 16 (76%) still had intercourse with a mean FSFI score of 19.5 ± 10.9 [4.8-36]. Main difficulties reported were troubles of lubrication, orgasm, and dyspareunia. Confection of a VRAM did not influence the recovery of SL (P = 0.717). Colpectomy reduced return of SL (P = 0.026).

CONCLUSION

Among women who had SL before APR, 76% still had sexual intercourse after. Colpectomy seems to reduce SL.

The clinical impact of primary sclerosing cholangitis in patients with an ileal pouch-anal anastomosis for ulcerative colitis

INTRODUCTION

Primary sclerosing cholangitis (PSC), a chronic inflammatory disease affecting the liver, is associated with ulcerative colitis (UC) in up to 75% of Northern European patients. These patients are at increased risk for the development of colorectal cancer, and the operation of choice is restorative proctocolectomy with an ileal pouch-anal anastomosis. However, complications such as pouchitis can occur, and studies have suggested that PSC is an independent risk factor for the development of pouchitis.

AIM

The aim of this study is to review and discuss the available literature on the effect of PSC on clinical outcomes of patients who undergo pouch surgery for UC. The outcomes reviewed comprise the incidence of pouchitis and pouch dysplasia/cancer and quality of life, including sexual function in UC patients with or without PSC.

METHODS

Pubmed/Medline and Embase searches were undertaken to obtain papers in English between 1966 and 2008. The keywords used were primary sclerosing cholangitis, ulcerative colitis, ileal pouch-anal anastomosis, quality of life, sexual function, dysplasia or cancer, pouchitis and orthotopic liver transplantation.

RESULTS

The incidence of pouchitis, pouch mucosal atrophy and risk of dysplasia appear to be greater in patients with associated PSC than in UC patients without PSC. Quality of life does not appear to be worse than in patients without PSC. Sexual function has not been studied in this subgroup of patients.

CONCLUSION

Pouchitis appears to be more common in the subset of UC patients with PSC, although there is clearly a need for further well-designed studies.

Long-term adjustment to living with an ileal pouch-anal anastomosis

PURPOSE

The aim of this study was to describe long-term adjustment to life with an ileal pouch-anal anastomosis after surgery for ulcerative colitis, to investigate the relationship of pouch function to adjustment, and to explore factors affecting quality of life.

METHODS

A total of 369 patients treated between 1982 and 1993 were included in the study. Questionnaires designed to assess bowel (pouch) function (Öresland score) and disease-specific adjustment (Swedish version of the Ostomy Adjustment Scale), plus open-ended questions regarding quality of life, were sent by mail. Open-ended questions were analyzed with qualitative content analysis.

RESULTS

A total of 252 patients (84%) returned the disease-specific adjustment questionnaire (141 males/111 females); median age, 51 (range, 26-77) years; median follow-up, 15 (range, 10-21) years after construction of the ileal pouch-anal anastomosis. High adjustment ratings were found for all statements, with the maximum median score of 6 on 28 of the 36 items. Items with the lowest ratings (median score, 5) pertained to things one would do if not for the IPAA, feeling free to travel, ability to enjoy sexual activities, comfort with body image, ability to laugh about awkward situations, confidence in the appliance, and whether the surgery helped with decisions on what things are most important in life. Participants with the lowest adjustment scores had low bowel function scores (P < .0001). Open-ended quality of life questions were answered by 150 patients (59.5%). The most important areas for quality of life were health, family, restroom access, and friends. Five categories emerged from the qualitative content analysis: living a "normal" life, food restrictions, physical limitations, influence of restroom access on social life, and being dependent on medical care.

CONCLUSIONS

Most participants had adjusted well to life with an ileal pouch-anal anastomosis and considered life to be normal. Good public restrooms were important for quality of life. Improving pouch function may help patients adjust to the postoperative state, but deeper understanding of reasons for poor adjustment despite good pouch function is needed.

Gender-specific differences in pelvic organ function after proctectomy for inflammatory bowel disease

BACKGROUND

Significant concern exists regarding the effect of proctectomy on sexual function in patients with IBD. Little is known about gender-specific differences.

OBJECTIVE

This study aimed to examine sexual function and quality of life in men and women with IBD before and after proctectomy.

DESIGN

This is a prospective cohort study.

SETTING

The study was conducted at a colorectal surgery center.

PATIENTS

The patients included in this study have IBD and underwent proctectomy or proctocolectomy.

INTERVENTION

The treatment provided was proctectomy or proctocolectomy.

MAIN OUTCOME MEASURES

Validated questionnaires were used to assess sexual function, quality of life, bowel habits, and urinary symptoms, and were completed before and 6 months after surgery.

RESULTS

Sixty-six participants (41 men and 25 women) were evaluated at baseline and 6 months after proctocolectomy or completion proctectomy. A total of 48 IPAAs (31 men and 17 women) and 18 end ileostomies (10 men and 8 women) were created. Men reported improved scores on the International Index of Erectile Function (P = .003), a modified Sexual Function Questionnaire (P = .001), Inflammatory Bowel Disease Quality of Life (P < .001), and SF-36 (Mental Component Summary, P = .003; Physical Component Summary, P = .001) after surgery. Women had improvement in the desire subscale of the Female Sexual Function Index (P = .03), Inflammatory Bowel Disease Quality of Life scores (P = .04), and SF-36 (Mental Component Summary, P = .02; Physical Component Summary, P = .02). There was no gender difference in the magnitude of change in scores before and after surgery for any of the measures.

LIMITATIONS

Small sample size and sexually inactivity in 50% of cohort may have had an impact on our findings.

CONCLUSIONS

Both men and women reported improvements in general and IBD-specific quality of life after surgery, but only men demonstrated several areas of improved sexual function. Women reported improved sexual desire but no other sexual function improvement. The postsurgical gender difference in sexual function, despite similar improvements in quality of life, may be accounted for by unexamined aspects of female sexual function.

Gender-related issues in the female inflammatory bowel disease patient

Inflammatory bowel diseases (IBDs) commonly affect women in their childbearing years. Women identify unique psychologic issues compared with men related to body image and their ability to bear children. The menstrual cycle can be disrupted because of disease activity, medications and/or malnutrition. Oral contraceptives can be used; however, monitoring for thromboembolic events should be performed. Women with IBD are potentially at risk of higher rates of cervical dysplasia and should be screened as are other immunocompromised women. Fertility rates are comparable to those of women without IBD. The risk of disease activity during pregnancy depends on the disease activity at the time of conception. Pregnancy for the majority of women is uncomplicated, although women with Crohn's disease do tend to deliver children of lower birthweights than do healthy women. The majority of medications used in the treatment of IBD are not harmful to the fetus and should be continued throughout pregnancy in order to maintain maternal health. Breastfeeding should not be discouraged and the majority of medications are safe for nursing. Menopause tends to occur earlier in women with IBD; the cause of this is unclear.

Does mesorectal preservation protect the ileoanal anastomosis after restorative proctocolectomy?

BACKGROUND AND AIMS

The technique of rectal dissection during restorative proctocolectomy might influence the rate of septic complications. The aim of this study was to analyze the morbidity of restorative proctocolectomy in a consecutive series of patients who had rectal dissection with complete preservation of the mesorectum.

PATIENTS AND METHODS

One hundred thirty-one patients who had restorative proctocolectomy for chronic inflammatory bowel disease with handsewn ileopouch-anal anastomosis (IPAA) and preservation of the mesorectal tissue were analyzed by chart reviews and a follow-up investigation at a median of 85 (14-169) months after surgery.

RESULTS

Only one of 131 patients had a leak from the IPAA, and one patient had a pelvic abscess without evidence of leakage, resulting in 1.5% local septic complications. All other complications including the pouch failure rate (7.6%) and the incidence of both fistula (6.4%) and pouchitis (47.9%) were comparable to the data from the literature.

CONCLUSION

The low incidence of local septic complications in this series might at least in part result from the preservation of the mesorectum. As most studies do not specify the technique of rectal dissection, this theory cannot be verified by an analysis of the literature and needs further approval by a randomized trial.

Development of pouchitis following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis: A role for serological markers and microbial pattern recognition receptor genes

BACKGROUND AND AIMS

Pouchitis, the most common complication after proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis, has been attributed to altered composition of faecal flora. We investigated the role of antimicrobial and antiglycan antibodies and polymorphisms in microbial pattern recognition receptor genes.

METHODS

Clinical charts of all 184 patients with ulcerative colitis who underwent IPAA between 1990-2004 were reviewed for pre- and post-operative disease course.

RESULTS

Follow-up data were available in 172 patients [67 female, median age at proctocolectomy 39.1 years]. During a median follow-up of 6.7 (interquartile range 3.7-10.5) years, 80 patients (47%) developed at least one episode of pouchitis. Cox proportional-hazard regression identified extra-intestinal manifestations [HR 1.78 (95%CI 1.10-2.88), p=0.020], a GT/TT genotype at Toll-like-receptor-1 S87I [HR 1.64 (1.01-2.66), p=0.047], anti-chitobioside carbohydrate antibodies [HR 2.03 (1.11-3.70), p=0.021] and young age at diagnosis [p=0.003] to be independently associated with pouchitis. Factors associated with chronic pouchitis, diagnosed in 33 patients (19%), were extra-intestinal manifestations [HR 2.45 (1.07-5.62), p=0.034], backwash ileitis [HR 3.15 (1.10-9.00), p=0.032], outer-membrane porin antibodies [HR 2.67 (1.20-5.94), p=0.016] and young age at proctocolectomy [p=0.008].

CONCLUSIONS

: The reported association with antibodies and Toll-like-receptor-1 supports the pathophysiological role of the faecal flora in the development of pouchitis.

A proposed classification of ileal pouch disorders and associated complications after restorative proctocolectomy

Both medical and surgical therapies for ulcerative colitis have inherent advantages and disadvantages that must be balanced for patients with moderate to severe disease. Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for the majority of patients with ulcerative colitis who require proctocolectomy. However, adverse sequelae of mechanical, inflammatory, functional, neoplastic, and metabolic conditions related to the pouch can occur postoperatively. Recognition and familiarization of the disease conditions related to the ileal pouch can be challenging for practicing gastroenterologists. Accurate diagnosis and classification of the disease conditions are imperative for proper management and prognosis.

Outcome after proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis

BACKGROUND

During the course of their disease, about 30% of patients with ulcerative colitis (UC) will undergo proctocolectomy with ileal pouch-anal anastomosis (IPAA). We evaluated the outcome of IPAA in a Belgian referral center.

METHODS

Clinical charts were reviewed for pre- and postoperative disease course, functional outcome, and complications in all patients with UC (n = 182) and indeterminate colitis (n = 2) who underwent IPAA in 1990-2004.

RESULTS

Follow-up data were available in 173 out of 184 patients (67 female, median age at proctocolectomy 39.0 years). Median functional Oresland score 1 year after IPAA was 3 (range 0-11). Early postoperative complications were seen in 27% of patients. After a median (interquartile range) follow-up of 6.5 (3.4-9.9) years, 35% of patients developed septic and/or obstructive complications. Forty-six percent of patients developed at least 1 episode of pouchitis. Risk factors for pouchitis were the presence of extraintestinal manifestations (odds ratio [OR] 1.92 (1.23-3.01), P = 0.004) and younger age at proctocolectomy (P = 0.004). Chronic pouchitis was present in 33 patients and associated with extraintestinal manifestations (OR 2.93 (1.13-7.62), P = 0.027), backwash ileitis (OR 9.28 (1.71-50.49), P = 0.010), and length of follow-up (P = 0.004). Pouch failure occurred in 5% of patients.

CONCLUSIONS

Although proctocolectomy with IPAA surgery has a good functional outcome, postoperative complications, especially pouchitis, remain considerable in patients with UC.

Quality of life after indefinite diversion/pouch excision in ileal pouch failure patients

OBJECTIVE

Pouch failure occurs in up to 10% of patients over a 10-year period for a variety of reasons. One surgical option is pouch excision (PE) and form a permanent ileostomy. This is a major procedure with potential serious complications. An alternative is indefinite diversion (ID) of the pouch without excision. The aim of this study was to examine the quality of life and functional outcome in these two groups of patients.

METHOD

Ninety-seven patients were identified from the database to have either PE or ID. Fifty-three patients (17 men) responded; comprising 31 patients after PE and 22 patients with ID in a case-control study and completed the SF-36 general health survey and the Cleveland Clinic Foundation (CCF) functional outcomes questionnaire.

RESULTS

There was no significant difference in the domains of SF-36 between the two groups (P > 0.18). All patients with PE had an end ileostomy whereas most patients with ID had a loop ileostomy (18 loop vs 4 end). There was no difference in stoma related complications except for stoma retraction in ID (7%vs 47%; P = 0.003). There was no significant difference in urinary symptoms between PE and ID groups (weak stream 26%vs 14%; P = 0.49, nocturia 22%vs 4%; P = 0.12, urgency 22%vs 9%; P = 0.28, urinary incontinence 22%vs 14%; P = 0.72 respectively). There was no difference in sexually active patients (73%vs 94%; P = 0.11). Of the seven male PE patients, five (71%) could achieve an erection and four (57%) could maintain an erection, compared with all 10 male patients in the ID group (P = 0.151 and 0.05 respectively). Thirty-three per cent of patients with PE and 62% of patients with ID reported that they would have pouch surgery again if indicated (P = 0.052) and 58% of patients with PE and 81% of patients with ID reported that they would recommend pouch surgery to others (P = 0.129). No case of dysplasia was seen in 18 of 22 ID patients in whom histology was available.

CONCLUSION

Quality of life after PE or ID was no different and male sexual function was significantly better after ID. Retraction of the stoma was more common in this group.

Surgical treatment of inflammatory bowel diseases and pregnancy

Ulcerative colitis (UC) and Crohn's disease (CD) affect women of reproductive age. Surgical intervention is often required. Therefore, the implications of disease treatment and pregnancy need to be understood. The standard surgery for UC is proctocolectomy, followed by ileal pouch anal anastomosis (IPAA). This review summarises the literature describing the effects of IPAA on gynaecologic and sexual health, fertility, pregnancy, labour and delivery. The emerging role of laparoscopic IPAA and the limited role of ileo-rectal anastomosis (IRA) are discussed. The experience with emergency surgery in pregnant women with ulcerative colitis is also presented. The literature explores two key issues of pregnancy in CD: the possible effect of pregnancy decreasing resection rates, and the optimal mode of delivery, especially in the setting of perianal CD. These two issues together with the available literature describing stoma function during pregnancy and the foetal outcome after surgical therapy are presented.

Determinants of male sexual function in inflammatory bowel disease: a survey-based cross-sectional analysis in 280 men

BACKGROUND

Problems with intimacy and sexual performance are among the major concerns of patients with inflammatory bowel disease (IBD). This study was performed to identify disease-related factors associated with low sexual function in men.

METHODS

Consecutive patients were surveyed using a standardized questionnaire. A random sample from the national patients' organization was also included. Low sexual function was defined as a score < -1 on a z-normalized scale of the International Index of Erectile Function. Results are presented as adjusted odds ratios (ORs) with 95% confidence interval (CI) based on multiple logistic regression.

RESULTS

280 questionnaires were available for analysis. Scores were similar between the groups and compared with general population means, with the exception of sexual desire. Of the clinical group, 44% felt severely compromised sexually due to their IBD. Erectile function was particularly sensitive to somatic problems (disease activity, OR 2.5, 95% CI: 1.3-4.9; diabetes, OR 7.0, 95% CI: 1.4-35.0). The influence of depressive mood was restricted to aspects of satisfaction (sexual satisfaction, OR 2.3, 95% CI 1.1-4.9; overall satisfaction OR 3.7, 95% CI: 1.7-8.3).

CONCLUSIONS

Sexual function was relatively better with longer disease duration and was not affected by the long-term severity of the disease.