Health-related quality of life after restorative proctocolectomy for ulcerative colitis: long-term results

Nurse-led surveillance of ileoanal pouch patients post-stoma reversal: outcomes at 12-month review

Restorative proctocolectomy with pouch anal anastomosis is the accepted treatment for suitable patients with ulcerative colitis, yet surveillance following stoma reversal remains contentious and involves several issues. While most patients are discharged from routine follow-up between 6 weeks and 3 months, some remain on surveillance pathways indefinitely. A high volume of patients require advice for many months or years after the stoma has been reversed, with the burden of surveillance on consultant-led clinics. Nurse-led follow-up after restorative proctocolectomy has been recognised for decades but has not been validated. This study reports the first protocol-based pathway for nurse-led follow-up. Using validated questionnaires, suitable pouch patients were followed up in nurse-led clinics over a 12-month period then sent an online survey to report on the service they received. Overall, most patients were satisfied with the nurse-led follow-up; however, further engagement and investment in the workforce and infrastructure is required to offer sustainable services.

Health-related quality of life and functional disorders after diverticular surgery

Diverticulosis and diverticulitis are leading indications for colorectal surgery in Western countries. Abdominal pain, functional disorders, and low health-related quality of life (HRQoL) can limit the outcome of abdominal surgery even in the absence of complications. Therefore, we aimed to review current evidence on postoperative long-term outcomes including HRQoL, functional disorders, abdominal pain, and patients' satisfaction after diverticular surgery for diverticulosis/diverticulitis. We performed a PubMed database search (inception: 17 December 2020). Identified publications were screened and outcome parameters extracted. In summary, HRQoL increased after diverticular surgery in 9 out of 10 longitudinal cohort studies. Similarly, patients' satisfaction with treatment and their choice to undergo surgery was commonly reported as high or very good, as reported in eight studies. In a randomized control trial and retrospective cohort, elective diverticular surgery was superior to conservative treatment regarding HRQoL. In cross-sectional analyses, chronic abdominal pain and functional disorders including defaecation disorders or diarrhoea/obstipation were found in a relevant fraction of patients. Incontinence ranged from 5% to 25% with insufficient data for comparison before and after surgery. However, functional disorders did not result in decreased HRQoL in most studies, and no increase in functional disorders was observed after elective diverticular surgery in longitudinal analyses. We conclude that HRQoL among operated patients with diverticular disease improved in most studies after surgery. Functional disorders and postoperative abdominal pain can be present after elective diverticular surgery; however, no increase in functional disorders was observed in longitudinal studies. Functional disorders after diverticular surgery need to be carefully discussed with the patient before surgery and a careful clinical assessment before surgery including incontinence scoring should be considered.

Ileal pouch-anal anastomosis in ulcerative colitis: outcomes, functional results, and quality of life in patients with more than 10-year follow-up

PURPOSE

Ileal pouch-anal anastomosis (IPAA) has become the surgical procedure of choice for patients with ulcerative colitis (UC). IPAA was incorporated into our institution in 1984, and thereafter, more than 200 procedures have been performed. The functional results and morbidity of this surgery have been reported previously. However, long-term functional outcomes and quality of life have not been evaluated.

METHODS

As a cohort study, we identified all consecutive patients who underwent IPAA for UC between 1984 and 2017 and selected those with more than 10-year follow-up. Demographic data, morbidity, and pouch survival information were obtained. Long-term functional results and quality of life were evaluated through an e-mail survey using the Öresland score and the Cleveland Global Quality of Life scales, respectively.

RESULTS

Of 201 patients, 116 met the inclusion criteria. Median follow-up was 20 (10-34) years. Early post-operative complications (30 days) were observed in 19 (16.4%) patients and 66 (56.9%) presented adverse events. The IPAA preservation rate at 10 and 20 years was 96.5% and 93.1%, respectively. Long-term functional scores presented a median of 6 (1-15) points. IPAA function was satisfactory in 11 (20.0%) patients, acceptable in 18 (32.7%), and deficient in 26 (47.3%). The median score for global quality of life was 0.8 (0.23-1.0) points.

CONCLUSION

IPAA as treatment for UC meets the expectations of cure of the disease, maintaining adequate long-term intestinal functionality associated with a good quality of life in most patients.

Diverted versus undiverted restorative proctocolectomy for chronic ulcerative colitis: an analysis of long-term outcomes after pouch leak short title: outcomes after pouch leak

BACKGROUND

The safety of undiverted restorative proctocolectomy (RPC) is debated. This study compares long-term outcomes after pouch leak in diverted and undiverted RPC patients.

METHODS

Data were obtained from a prospectively maintained registry from a single surgical practice. One-stage and staged procedures with an undiverted pouch were considered undiverted pouches; all others were considered diverted pouches. The outcomes measured were pouch excision and long-term diversion defined as the need for loop ileostomy at 200 weeks after pouch creation. Regression models were used to compare outcomes.

RESULTS

There were 317 diverted and 670 undiverted pouches, of which 378 were one-stage procedures. Pouch leaks occurred in 135 patients, 92 (13.7%) after undiverted, and 43 (13.6%) after diverted pouches. Eighty-six (64%) leaks were diagnosed within 6 months of pouch creation. Undiverted patients underwent more emergent procedures within 30 days of pouch creation (p < 0.01). Pouch excision occurred in 14 (33%) diverted patients and 13 (14%) undiverted patients (p = 0.01). Thirteen (32%) diverted patients and 18 (21%) undiverted patients (p = 0.17) had ileostomies at 200 weeks after surgery. In multivariable analyses, diverted patients had a higher risk of pouch excision (HR 3.67 p < 0.01), but similar rates of ileostomy at 200 weeks (HR 1.8, p = 0.19) compared to undiverted patients.

CONCLUSIONS

Despite a likely selection bias in which "healthier" patients undergo an undiverted pouch, our data suggest that diversion does not prevent pouch excision and the need for long-term diversion after pouch leak. These findings suggest that undiverted RPC is a safe procedure in appropriately selected patients.

Anxiety, depression, and inflammation after restorative proctocolectomy

PURPOSE

Anxiety and depression (A&D) are more common in inflammatory bowel disease (IBD) and in IBD patients who undergo proctocolectomy with ileal pouch-anal anastomosis (IPAA). Our aim was to test the hypothesis that chronic inflammatory conditions in IPAA are associated with increased incidence of A&D.

METHODS

Retrospective cohort study at a single tertiary care referral center using a consented IBD and colon cancer natural history registry. Demographic and clinical factors, including surgical and psychiatric history, were abstracted.

RESULTS

We compared A&D rate in three cohorts: (1) ulcerative proctocolitis with IPAA (UC) (n = 353), (2) Crohn's disease/indeterminate proctocolitis with IPAA (CDIC) (n = 49), and (3) familial adenomatous polyposis with IPAA (FAP) (n = 33). Forty-six CDIC patients (93.9%) demonstrated pouch-related inflammation, while 126 UC patients (35.7%) and 2 FAP patients (6.1%) developed pouchitis. CDIC had a higher rate of A&D co-diagnosis compared to UC and FAP (20.4 vs.12.7 vs.12.1% respectively; p < 0.05). UC patients with pouchitis also exhibited a higher rate of A&D than UC without pouchitis (19.8 vs.8.8%; p < 0.05). Multivariable analysis demonstrated that pre-operative corticosteroid use (OR = 4.46, CI = 1.34-14.87, p < 0.05), female gender (OR = 2.19, CI = 1.22-3.95, p < 0.01), tobacco use (OR = 2.92, CI = 1.57 = 5.41, p < 0.001), and pouch inflammation (OR = 2.37, CI = 1.28-4.39, p < 0.05) were each independently associated with A&D in these patients.

CONCLUSIONS

Anxiety and depression were more common in patients experiencing inflammatory conditions of the pouch. UC without pouchitis and FAP patients demonstrated lower rates of A&D (that were comparable to the general population), implying that having an IPAA alone was not enough to increase risk for A&D. Factors independently associated with A&D in IPAA included an inflamed pouch, corticosteroid use, smoking, and female gender.

Quality of life of ulcerative colitis patients treated surgically with proctocolectomy and J-pouch formation: a comparative study before surgery and after closure of the defunctioning ileostomy

Background

Ulcerative colitis (UC) is a lifelong disease with a relapse-remission pattern that affects patients' social and psychological wellbeing. Restorative proctocolectomy and J-pouch formation is the gold-standard surgical procedure in cases where symptoms are refractory to currently available medical treatment. The aim of this study was to assess patients' quality of life (QoL) in order to evaluate the efficiency of surgery and patients' symptomatology.

Methods

We performed a prospective comparative study of the QoL of 47 patients with UC, treated surgically. As research tools, we used the Inflammatory Bowel Disease Questionnaire (IBDQ) and the Cleveland Global Quality of Life (CGQL) questionnaire. Parametric and non-parametric tests were used in order to correlate areas of QoL and other selected factors, such as marital status, sex, age, and education.

Results

The mean scores before and after closure of the ileostomy were 153.29 and 178 for the IBDQ (P=0.0025), and 17.4 and 23.42 for the CGQL (P<0.001), suggesting an overall improvement in QoL. The research showed that there was no specific QoL factor, such as intestinal, systemic, emotional or social life symptoms, that improved significantly more than the others (P=0.99). The IBDQ showed that patients aged less than 20 years (P<0.001), female patients (P=0.03) and patients with secondary education (P<0.001) reported the greatest improvement.

Conclusions

The QoL in UC patients treated surgically improved following closure of the de-functioning ileostomy. QoL studies are encouraged to optimize and maintain high standards of surgical care, and they could potentially be used for assessment of therapeutic efficacy.

Ileal pouch-anal anastomosis 20 years later: is it still a good surgical option for patients with ulcerative colitis?

PURPOSE

Short-term results after ileo-pouch anal anastomosis (IPAA) are well established; data are conflicting in long-standing patients. We retrospectively evaluated long-term complications and functional results after follow-up longer than 20 years.

METHODS

Two hundred five patients with follow-up longer than 20 years have been identified out of 1112 IPAA performed in our institution; of these, 20 cases were lost at follow-up or decline to take part at the study. We evaluated long-term complications and failure rate also according to changes in histological diagnosis. Changes in functional results and quality of life (QoL) were analyzed at 5 and 20 years after IPAA.

RESULTS

Pouch failure rate was 10.8 % (35 % due to misdiagnosed Crohn). Incidences of fistulas, anastomotic stenosis, chronic pouchitis, and pre-pouch ileitis were 17.3, 12.9, 28.6, and 7.6 %, respectively. Most of the patients reported good functional outcomes. Day-time evacuations at 5 and after 20 years were 4.3 and 4.8 (p = n.s.) while during night-time were 0.8 and 1.2 (p < 0.05). Urgency was 6 and 9.4 % (p = n.s.), respectively; need of antimotility drugs was 16 and 35 % (p < 0.001). Dietary limitations and work restrictions were similar over time. Only sexuality got worse during follow-up. Satisfaction for surgery was always high and it did not change over time.

CONCLUSION

IPAA is still an excellent surgical option for UC with a low rate of pouch failure even after more than 20 years. Despite a slight worsening of functional results over time, the QoL remained high and most patients expressed satisfaction with the procedure and were willing to recommend it to others.

Health-related quality of life assessment among patients with inflammatory bowel diseases after surgery - review

Aim of the work was to review systematically the published literature addressing whether quality of life (QoL) and health-related QoL (HRQoL) are influenced by surgery among patients with inflammatory bowel disease (IBD). Electronic databases and published articles were searched to identify relevant studies published in the years 1990-2015. Then, a multistep selection was undertaken to identify articles that met specific selection criteria, such us specific key-words (IBD, HRQoL, ulcerative colitis (UC), Crohn's disease (CD), and surgery), and the population was assessed (studies concerning patients < 18 years old were excluded). The review included 27 studies that were evaluated in the context of the influence of surgery on QoL and HRQoL. Concluding, with the increase in the incidence of IBD, monitoring of QoL is an important indicator of the health effects at each stage of the surgical treatment.

Palliative therapy for esophageal cancer: laser therapy alone is associated with a better functional outcome

The aim of our study was to compare functional outcome and survival in patients who underwent laser therapy (LT) or laser therapy and esophageal stenting (LTES) to palliate inoperable esophageal cancer. Two hundred and twenty-seven consecutive patients who had endoscopic palliation for esophageal cancer were enrolled in this retrospective study. One hundred and sixty-four underwent LT alone and 63 had LTES. A dysphagia score was adopted (0: absolute dysphagia; 1: liquid diet; 2: semisolid diet; 3: free diet). Survival analysis and non parametric statistics were performed. Patients in the LTES group reported a significantly worse dysphagia score than LT patients (p < 0.01). LTES patients more frequently reported difficulty swallowing than LT patients (p < 0.01). No difference between LTES and LT groups was observed in terms of overall survival. Only radiotherapy resulted in a significant predictor of better survival (p = 0.007). Despite a similar survival, LTES is a predictor of a worse functional palliation than LT alone. Radiotherapy was associated with better survival in patients treated with LT. Therefore, these data seem to suggest that a combination of endoscopic LT and external radiotherapy may yield the best results in palliative care of advanced esophageal cancer.

Impact of jejunostomy during esophagectomy for cancer on health related quality of life

BACKGROUND

The aim of this study was to evaluate the impact of jejunostomy during esophagectomy for cancer on postoperative health-related quality of life (HRQL).

METHODS

We evaluate all consecutive patients who underwent esophagectomy for cancer at the surgical oncology unit of the Veneto Institute of Oncology (IOV-IRCCS) between January 2008 and March 2014. The primary outcome was HRQL, which was assessed using nine scales of EORTC C30 and OES18 questionnaires. General linear models were estimated to evaluate mean score difference (MD) of each selected scale in patients with and without jejunostomy, adjusting for clinically relevant confounders. The secondary outcomes were morbidity, hospital stay, postoperative weight loss and postoperative albumin impairment.

RESULTS

Jejunostomy was performed in 40 on 109 patients (41.3%) who participated in quality of life investigation. A clinically and statistically significantly worse eating at admission (P=0.009) became not clinically significant at 3 months after surgery (MD =9.1). Jejunostomy was associated to clinically and statistically significantly poorer emotional function (EF) at 3 months after surgery (MD =-15.6; P=0.04). Hospital stay was longer in jejunostomy group (median, 20 vs. 17 days, P=0.02).

CONCLUSIONS

In our series patients who had a jejunostomy during esophagectomy had been selected for their risk for postoperative complication. However, their postoperative outcome was actually similar compared to those without jejunostomy. Nevertheless, jejunostomy was associated to clinically and statistically significantly poorer EF at 3 months after surgery. Therefore, patient candidate to esophagectomy and feeding jejunostomy should receive additional psychological support.

Health-related quality of life in pediatric ulcerative colitis patients on conventional medical treatment compared to those after restorative proctocolectomy

PURPOSE

Health-related quality of life (HRQL) is not well studied in proctocolectomy patients with pediatric onset of ulcerative colitis (UC). We aimed to (1) compare the HRQL of proctocolectomy patients with those treated with conventional therapy and (2) determine factors that influence HRQL in UC patients < 18 years.

METHODS

Chart review was done on patients diagnosed with pediatric onset of UC (<18) at the Stollery Children's Hospital. HRQL was evaluated in 88 patients using disease- and age-specific questionnaires; IMPACT III (<18) and Inflammatory Bowel Disease Questionnaire (IBDQ; ≥18). Demographics, disease characteristics, disease index (PUCAI), HRQL EuroQoL visual analog scale (EQ-5D/VAS) were collected and analyzed from all patients.

RESULTS

Sixty-five respondents completed the IMPACT III (74 %) and 23 patients completed the IBDQ (26 %). Thirty-three surgical patients (34 %) responded (mean IMPACT III score = 148.9 ± 12.7; mean IBDQ = 171.2 ± 40.1). There was no significant difference in IMPACT III scores of surgical patients vs. medically treated patients (148.9 ± 12.7 vs. 140.6 ± 19.4, p = 0.09). Patients with high IMPACT scores (>143 points) were most likely to be in remission (p = 0.05), they were less likely to be on medication (p < 0.05), have parent/guardian with postsecondary education (p = 0.01), did not suffer from fatigue (p < 0.01), and did not report depression (p < 0.02). The IMPACT correlation with PUCAI (adjusted r (2) = 0.33) and EQ-VAS (adjusted r (2) = 0.45) was strong.

CONCLUSIONS

Surgical patients reported to have a HRQL comparable to or better than the nonsurgical patients. Depression, fatigue, parent/guardian education, and drugs influence HRQL.

Self-reported assessment of health-related quality of life in children who underwent restorative proctocolectomy with ileal J-pouch anal anastomosis for ulcerative colitis

PURPOSE

To clarify health-related quality of life (HRQOL) by self-evaluation after restorative proctocolectomy with ileal J-pouch anal anastomosis (IPAA) in children with ulcerative colitis, a questionnaire using the Pediatric Quality of Life Inventory™ 4.0 (PedsQL) was administered.

METHODS

The PedsQL was administered to 13 consecutive children (mean age 14.5 years) who underwent IPAA between 2005 and 2010 in our hospital and age-matched healthy controls. The mean duration after IPAA was 2.5 years (range 0.08-6 years) at the time of this study. Healthy children completed the same questionnaire by retrospective imaging during the past 1 month by the PedsQL evaluation policy.

RESULTS

Patients' total score and each functioning score after IPAA reached the same levels as those in healthy controls. Soiling, pouchitis occurrence, and bowel movements had no significant relationship to the PedsQL total score and each functioning score.

CONCLUSIONS

Interference of physical activity, emotional status, and social life caused by refractory ulcerative colitis (UC) worsens patients' HRQOL. IPAA could resolve these problems in children with UC and result in an HRQOL comparable with that in healthy children.

History of and current issues affecting surgery for pediatric ulcerative colitis

Pediatric ulcerative colitis (UC) is reportedly more extensive and progressive in its clinical course than adult UC. Therefore, more aggressive initial therapies and more frequent colectomies are needed. When physicians treat pediatric UC, they must consider the therapeutic outcome as well as the child's physical and psychological development. Mucosal proctocolectomy with ileal J-pouch anal anastomosis is currently recommended as a standard curative surgical procedure for UC in both children and adults worldwide. This procedure was developed 100 years after the first surgical therapy, which treated UC by colon irrigation through a temporary inguinal colostomy. Predecessors in the colorectal and pediatric surgical fields have struggled against several postoperative complications and have long sought a surgical procedure that is optimal for children. We herein describe the history of the development of surgical procedures and the current issues regarding the surgical indications for pediatric UC. These issues differ from those in adults, including the definition of toxic megacolon on plain X-rays, the incidence of colon carcinoma, preoperative and postoperative steroid complications, and future growth. Surgeons treating children with UC should consider the historical experiences of pioneer surgeons to take the most appropriate next step to improve the surgical outcomes and patients' quality of life.

Quality of life, health-related quality of life and health status in patients having restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis: a systematic review

AIM

There are numerous studies on quality of life (QoL), health-related quality of life (HRQoL), and health status (HS) in patients undergoing surgery for ulcerative colitis. A systematic review of published literature was conducted to establish the quality of these studies and to determine QoL, HRQoL, and HS in patients after ileal pouch-anal anastomosis for ulcerative colitis.

METHOD

All published studies describing QoL, HRQoL, and HS in adult patients in combination with ileal pouch-anal anastomosis for ulcerative colitis were reviewed systematically. No time or language limitations were applied. Relevance was established on the basis of three pre-specified selection criteria: 1) ileal pouch-anal anastomosis was performed for ulcerative colitis, 2) QoL, HRQoL, and HS were reported as outcome of the study and 3) studies reported a minimum follow-up after surgery for 12 months. Outcome variables were results of QoL, HRQoL, and HS, characteristics of the study population, pouch construction, duration of follow-up, and time of assessment in months before and after restorative surgery. Descriptive data synthesis was performed by tabulation displaying the methodological quality, study characteristics and conclusions on QoL, HRQoL, and HS measurements in the studies.

RESULTS

The review included 33 studies comprising 4790 patients. Three were graded to be of high quality, 23 of moderate quality and seven of low quality. All reported improved HS and the majority reported improved HRQoL. However, none of the studies reported on QoL.

CONCLUSION

The HRQoL and HS of patients with ulcerative colitis improved 12 months after restorative proctocolectomy with an ileal pouch-anal anastomosis and were indistinguishable from the HRQoL and HS of the normal healthy population.

Systematic review of health-related quality of life after esophagectomy for esophageal cancer

This study is aimed to assess the long-term health-related quality of life (HRQL) of patients after esophagectomy for esophageal cancer in comparison with es-tablished norms, and to evaluate changes in HRQL during the different stages of follow-up after esophageal resection. A systematic review was performed by searching medical databases (Medline, Embase and the Cochrane Library) for potentially relevant studies that appeared between January 1975 and March 2011. Studies were included if they addressed the question of HRQL after esophageal resection for esophageal cancer. Two researchers independently performed the study selection, data extraction and analysis processes. Twenty-one observational studies were included with a total of 1282 (12-355) patients. Five studies were performed with short form-36 (SF-36) and 16 with European Organization for Research and Treatment of Cancer (EORTC) QLQ C30 (14 of them also utilized the disease-specific OES18 or its previous version OES24). The analysis of long-term generic HRQL with SF-36 showed pooled scores for physical, role and social function after esophagectomy similar to United States norms, but lower pooled scores for physical function, vitality and general health perception. The analysis of HRQL conducted using the Global EORTC C30 global scale during a 6-mo follow-up showed that global scale and physical function were better at the baseline. The symptom scales indicated worsened fatigue, dyspnea and diarrhea 6 mo after esophagectomy. In contrast, however, emotional function had significantly improved after 6 mo. In conclusion, short- and long-term HRQL is deeply affected after esophagectomy for cancer. The impairment of physical function may be a long-term consequence of esophagectomy involving either the respiratory system or the alimentary tract. The short- and long-term improvement in the emotional function of patients who have undergone successful operations may be attributed to the impression that they have survived a near-death experience.

Long-Term Followup of Patients with Active J-Reservoirs after Restorative Proctocolectomy for Ulcerative Colitis with regard to Reservoir Function, Mucosal Changes, and Quality of Life

Objective. Study the functional results and mucosal changes in the ileal pouch after restorative proctocolectomy with J-reservoir for ulcerative colitis. Material and Methods. Followup study of 125 patients with J-reservoir with one disease-specific- and one general (SF-36) quality of life-questionnaire, rectoscopy with biopsies, and stool samples to evaluate inflammation, dysplasia, presence of Helicobacter pylori and calprotectin level. Results. Fourteen J-reservoirs were removed or deactivated, leaving 111 patients for followup. The followup time was 6.8 (1-15) years. 87.4% of the patients were satisfied. 93.1% had some kind of functional restriction: food- (75.5%), social- (28.9%), physical- (37%) or sexual restriction (15.3%). 18.6% had often or sometimes faecal incontinence. Low daytime faecal frequency was associated with good quality of life. 13 patients (12.6%) had a less favourable result. There was no pouch-dysplasia. Calprotectin levels were increased in patients with visible pouch inflammation or history of pouchitis. HP was diagnosed by RUT in 42.3%, but was not associated with inflammation or pouchitis. Conclusions. Most patients were satisfied with the J-reservoir in spite of a high frequency of various restrictions. 12.6% (13 patients) had a less favourable functional result, partly due to a high frequency of defecations, pain, pouchitis and inflammation.

Long-term followup with evaluation of the surgical and functional results of the ileal pouch reservoir in restorative proctocolectomy for ulcerative colitis

Aims. Evaluate the early and long term surgical and functional results of the ileal pouch-reservoir (IPAA) in patients with intractable ulcerative colitis. Material and Methods. Followup of 134 consecutive patients with W-or J-ileal pouch by diseases-specific and general health (SF-36) questionnaire. In the first 44 patients, early and late followup was performed. Results. Followup was performed 7.4 years (0.5-17 years) after construction of W (n = 9) and J (n = 125) ileal pouch, which had similar results. There were 14.9% early and 43.6% late complications with 12.7% early and 19.5% late reoperations. Protecting loop-ileostomy used in 54 patients (43.9%), did not protect against complications. Thirteen reservoirs (9.8%) were resected (n = 8) or deactivated (n = 5) due to functional failure. Operation time, postoperative complications and pouchitis were determinators for reservoir failure and reduced quality of life. The functional results at followup of 44 patients at 2.5 years (0.8-6.7 years) and 11.5 years (8.2-19.2 years) were remarkably similar. Conclusions. IPAA is a good option for most patients when medication fails. 10% experience failure with inferior quality of life. Protective stoma will not reduce failure rates. After an initial time period, reservoir function will not change over time.

Long-term health-related quality of life after minimally invasive surgery for diverticular disease

BACKGROUND AND AIMS

The aim of this multicentric study was to evaluate the disease specific and the generic quality of life in patients affected by colonic diverticular disease (DD) who had undergone minimally invasive or open colonic resection or who had been treated with medical therapy in the long-term follow-up.

PATIENTS AND METHODS

Seventy-one consecutive patients admitted to the departments of surgery of Padova and Arzignano Hospitals for DD were interviewed: 22 underwent minimally invasive colonic resection, 24 had open resection, and 25 had only medical therapy. The interview focused on disease specific and generic quality of life, body image, and disease activity.

RESULTS

Padova Inflammatory Bowel Disease Quality of Life (PIBDQL) was validated for the use in DD patients. PIBDQL scores were significantly worse in all patients with DD than those obtained by healthy subjects and it correlated with the symptoms score. The generic quality of life seemed similar in patients who had minimally invasive colonic resection compared with healthy subjects. Body Image Questionnaire scores correlated inversely with the presence of a stoma.

CONCLUSIONS

Disease activity resulted as the only independent predictor of the disease-specific quality of life. In fact, DD affected bowel function and quality of life of patients in the long-term follow-up regardless of the type of therapy adopted. The presence of a stoma affected the patients' body image.

Quality of life after surgery of the alimentary tract

In recent decades, patient-reported outcomes have become important in clinical medicine. Nowadays, health-related quality of life (HRQOL) is considered a primary outcome in many clinical trials, and it is often the major criterion for judging treatment success. At the beginning of the 21st century, morbidity and mortality rates after surgery of the alimentary tract have dropped dramatically and they can no longer be considered the only outcome measures to determine the success of a surgical procedure. QOL can yield a definitely more patient-orientated measure of outcome that provides us with a more formal measure of the patient’s judgment and desires, which can influence treatment decisions. Nevertheless, despite a very large number of published papers on HRQOL, there is some skepticism on the value of HRQOL and other patient-related outcomes. Therefore, this topic highlight aims to assess how QOL after surgery of the alimentary tract is covered in the medical literature. Different reviews have analyzed the topic according to different points of view: benign and malignant disease; curative and palliative treatment; open and minimally invasive surgical approach; traditional and newly introduced surgical procedures. This topic highlight does not aim to cover all the possible diseases or different surgical procedures, but it does describe the different approaches in order to give the reader a broad spectrum of analysis of QOL after surgery. This quick overview could stimulate the reader to form his/her own opinion about how to use this primary outcome measure.

Health related quality of life after surgery for colonic diverticular disease

Diverticular disease (DD) of the colon is very common in developed countries and is ranked the fifth most important gastrointestinal disease worldwide. The management of acute diverticulitis without perforation and peritonitis is still debated. Health related quality of life (HRQL), subjectively perceived by patients, is becoming a major issue in the evaluation of any therapeutic intervention, mainly in patients with chronic disease. To date only a few published studies can be found on Medline examining HRQL in patients with DD. The aim of this study was to review the impact of surgery for DD on HRQL. All Medline articles regarding HRQL after surgery for colonic DD, particularly those comparing different surgical approaches, were reviewed. DD has a negative impact on HRQL with lower scores in bowel function and systemic symptoms. Both surgery-related complications and disease activity have a significant impact on patients' HRQL. While no significant differences in HRQL between different operations for DD in non-randomized studies were revealed, the only prospective double-blind randomized study that compared laparoscopic and open colectomy found that patients undergoing laparoscopic colectomy had significantly reduced major postoperative complication rates and subsequently had better HRQL scores. Formal assessment of HRQL could be a good instrument in the selection of appropriate patients for elective surgery as well as in the assessment of surgical outcome.

Development of a pouch functional score following restorative proctocolectomy

BACKGROUND

The influence of function on quality of life after primary restorative proctocolectomy (RPC) was determined with the aim of developing a pouch functional score.

METHODS

The Cleveland Global Quality of Life (CGQL) score was determined in 4013 patients undergoing RPC between 1977 and 2005 (mean(s.d.) follow-up 7.0(5.1) years; 13 105 follow-up episodes). Linear regression analysis was used to identify independent symptom domains of function as possible predictors of quality of life to develop and validate a pouch functional score.

RESULTS

CGQL scores at 1, 5, 10, 15 and 20 years were 85.0, 87.5, 87.5, 85.0 and 82.5 respectively (P = 0.001). On multivariable analysis, the symptom domains of stool frequency (24 h, nocturnal), urgency, incontinence and medication (antidiarrhoeals, antibiotics) were independently associated with CGQL (P < 0.001). The beta coefficients within each symptom domain were then adjusted to create a scale of 0-30 for practical use, the Pouch Functional Score (PFS), which correlated with the CGQL score (r(s) = -0.47, P < 0.001).

CONCLUSION

Stool frequency, urgency, incontinence and need for medication are major determinants of quality of life following RPC. The PFS demonstrated good correlation with CGQL.

Poor catch-up growth after proctocolectomy in pediatric patients with ulcerative colitis receiving prolonged steroid therapy

PURPOSE

The aim of the present study was to review the complications and growth after proctocolectomy and ileal J-pouch anal anastomosis (IPAA) in pediatric ulcerative colitis (UC) patients receiving prolonged steroid therapy.

PATIENTS AND METHODS

We experienced 209 patients with UC who received IPAA between September 2000 and June 2009, and reviewed the medical records of 16 pediatric (<15 years of age at operation and >1 year follow-up) patients.

RESULTS

The total dose of preoperative prednisolone (PSL) was 9,829 +/- 9,283 mg (mean +/- 1SD 880-30,000 mg). The dose of preoperative PSL was significantly related to the occurrence of preoperative major steroid-related complications (SRC). Older patients (>11 years at operation) grew more slowly compared with younger patients (< or =11 years at operation) for 5 years. There was a significant difference in height between PSL high-dose (>10,000 mg) and PSL low-dose (< or =10,000) patients for 5 years after colectomy. The mean height of PSL high-dose patients did not reach the standard level during the 5-year follow-up.

CONCLUSION

Preoperative prolonged high steroid therapy may disturb growth recovery of pediatric patients with UC, while early induction of colectomy allowed pediatric patients with PSL dependency to become free of steroids and get normal growth.

Practical strategies for treating postsurgical bowel dysfunction

Postsurgical bowel dysfunction is a potential complication for patients undergoing ileoanal anastomosis, restorative proctocolectomy, and low anterior anastomosis. In our setting, these patients are referred to the Anorectal Physiology Clinic at the Townsville Hospital, Queensland, for comprehensive behavioral therapy. The goals of the therapy are as follows: improve stool consistency, improve control over stool elimination, decrease fecal frequency and rectal urgency, fecal continence without excessive restrictions on food and fluid intake, and increase quality of life. This article outlines our holistic approach and specific treatment strategies, including assessment, education, support and assistance with coping, individualized dietary and fluid modifications, medications, and exercise. Biofeedback is used to help patients improve anal sphincter and pelvic floor muscle function and bowel elimination habits. Information on the biofeedback component of the treatment program will be described in a subsequent article.

Restorative proctocolectomy for inflammatory bowel disease: the Padova prognostic score for colitis in predicting long-term outcome and quality of life

BACKGROUND

In 10-20% of cases, it is impossible to distinguish between ulcerative colitis and Crohn's colitis, affecting the possibility to predict the long-term outcome after restorative proctocolectomy (RPC). The study aimed to assess the accuracy of a new prognostic score for inflammatory bowel diseases (IBD) colitis [the Padova Prognostic Score for Colitis (PPSC)] in predicting long-term clinical/functional outcome and quality of life after RPC.

MATERIALS AND METHODS

The PPSC was created by the integration of histological and clinical information. The accuracy of the PPSC was tested in predicting long-term clinical outcome (i.e. pouch complications/survival) and quality of life of 58 consecutive patients who had undergone RPC in our institute from 1984 to 2004. Clinical outcome was assessed with an ad hoc functional questionnaire and the revision of the hospital and outpatients clinic notes. Quality of life surveys were carried out with the Padova IBD Quality of Life (PIBDQL) and with Cleveland Global Quality of Life (CGQL) scores.

RESULTS

The PPSC predicted pouch fistulae (accuracy = 84.5%; sensitivity = 50%; specificity = 90%) and changes in sexual life (accuracy = 71%; sensitivity = 23%; specificity = 87%). The PPSC also predicted the PIBDQL score with an accuracy of 62%, a sensitivity of 28% and a specificity of 97%, whilst it predicted the CGQL score with an accuracy of 29%, a sensitivity of 12% and a specificity of 80%. The PPSC failed to predict pouchitis or pouch failure.

CONCLUSIONS

The Padova Prognostic Score for Colitis proved effective in predicting pouch fistulae or abscesses, but not pouchitis and pouch failure. The PPSC was accurate in predicting disease-specific quality of life.

Validation of an English version of the Padova quality of life instrument to assess quality of life following ileal pouch anal anastomosis

OBJECTIVE

Ileal pouch anal anastomosis (IPAA) is the procedure of choice for most patients requiring surgery for ulcerative colitis and familial adenomatous polyposis because of its perceived improvement in health-related quality of life (HRQL). The aims of this cross-sectional study were to validate an English version of the Padova Inflammatory Bowel Disease Quality of Life questionnaire (PIBDQL) in patients undergoing IPAA and to investigate the pre- and postoperative predictors of long-term HRQL.

MATERIALS AND METHODS

In May 2005, the English version of the PIBDQL, Short Inflammatory Bowel Disease Questionnaire, and the SF-36 were mailed to 1,379 patients who underwent IPAA at the Mount Sinai Hospital between 1982 and 2004. The test-retest reliability, internal consistency, construct validity, and discriminative ability of the English version of the PIBDQL were assessed.

RESULTS

Nine hundred fifty-five patients (69%) (475 female, 480 male; mean, age 43 years) returned the questionnaires. The mean PIBDQL score was 21.1 (3.4), suggesting good quality of life. Test-retest reliability [intraclass correlation coefficient (ICC) = 0.784] and internal consistency (Cronbach's alpha = 0.83) were good. Construct validity and discriminative ability of the English version of PIBDQL were adequate. Multivariate analysis revealed that women (p < 0.01) and Crohn's disease patients (p < 0.01) had significantly worse PIBDQL scores.

CONCLUSIONS

The English version PIBDQL is a reliable and valid disease-specific instrument for assessing quality of life in patients with IPAA. In this series, female gender and CD were significant predictors of worse HRQL.

Pouchitis: an evolving clinical enigma--a review

While the overall incidence of pouchitis is low, extensive research continues at clinical and experimental levels in attempts to unravel its etiology. The ileal pouch and pouchitis together represent a unique in vivo opportunity to study mucosal adaptation and inflammation in depth. In the recent past, molecular data relating to pouchitis has significantly expanded. These data provide invaluable insight into intracellular and extracellular events that underpin mucosal adaptation and inflammation. Advances in classification, risk factor evaluation, and prevention have meant that a review of this data, as well as its relationship to our current understanding of pouchitis, is both timely and warranted. Therefore, the aim of this review is to summarize recent data in the context of the established literature.

Septic complications after restorative proctocolectomy do not impair functional outcome: long-term follow-up from a specialty center

PURPOSE

After restorative proctocolectomy, 7 to 8 percent of patients may have a pouch leak. Concern exists that pouch leak may be associated with impaired functional outcome. We evaluated patients who underwent restorative proctocolectomy to determine whether pouch leak adversely affected long-term functional outcome and quality of life.

METHODS

We queried our prospectively maintained database of patients who underwent restorative proctocolectomy for demographic and clinical data. We sent a long-term outcome questionnaire to patients, including the validated Fecal Incontinence Severity Index and Cleveland Global Quality of Life scores. Pouch leak was identified by clinical or radiographic evidence of leak. Patients with leak were compared with those without to determine the impact on long-term functional outcome or quality of life.

RESULTS

A total of 817 patients were available for follow-up and 374 patients (46 percent) completed questionnaires. The group with (n = 60; 16 percent) and without (n = 314; 84 percent) leak had similar demographics. The median Fecal Incontinence Severity Index score (15.3 vs. 14.7, P = 0.77), Cleveland Global Quality of Life score (0.79 vs. 0.81, P = 0.48), and bowel movements per 24 hours (7.92 vs. 7.88, P = 0.92) were similar. The pouch loss/permanent ileostomy rate was higher in those who leaked (13.3 vs. 0.9 percent, P < 0.001).

CONCLUSIONS

Anastomotic leak after restorative proctocolectomy does not adversely affect long-term quality of life or functional outcome. However, pouch loss/permanent ileostomy is significantly more likely in patients who have had an anastomotic leak.

Surgery for inflammatory bowel disease

Despite the new and ever expanding array of medications for the treatment of inflammatory bowel disease (IBD), there are still clear indications for operative management of IBD and its complications. We present an overview of indications, procedures, considerations, and controversies in the surgical therapy of IBD.

Minimally invasive surgery for colorectal cancer: quality of life, body image, cosmesis, and functional results

BACKGROUND

The aims of this cross-sectional study were to assess the long-term quality of life, the body image, and the cosmetic and functional results in patients who had laparoscopic-assisted for colorectal cancer.

METHODS

Forty-two patients were enrolled in this study: 21 consecutive patients who had undergone laparoscopic-assisted colonic resection and 21 patients who had open colonic resection, selected according to stage, gender, age, cancer site, and type of resection. The patients answered four questionnaires about their quality of life, body image, functional, and cosmetic results. Nonparametric tests were used for statistical analysis.

RESULTS

Postoperative hospital stay was shorter in patients who had laparoscopic-assisted resection. The cosmetic score was significantly better in the laparoscopic-assisted group than in the open group (p < 0.01). In spite of similar overall body image score, patients who had a laparoscopic-assisted resection reported a significantly better satisfaction with their own body (p = 0.05). Quality-of-life and functional results were similar in both groups.

CONCLUSIONS

The cosmetic results and the consequent satisfaction with the body were significantly better after laparoscopic assisted resection compared to equivalent open procedure. These effects seemed to be temporary but they could help patients to accept the burden of surgery.

Evolution of the restorative proctocolectomy and its effects on gastrointestinal hormones

Gastrointestinal (GI) peptide hormones are chemical messengers that regulate secretory, mechanical, metabolic, and trophic functions of the gut. Restorative proctocolectomy (RPC) or resection of the colon and rectum with maintenance of intestinal continuity through the construction of an ileal pouch reservoir and preservation of the anal sphincters has become the standard of care for the surgical treatment of ulcerative colitis and familial adenomatous polyposis. The manipulation of the digestive system to create the ileal pouch involves altering gut-associated lymphoid tissue among other anatomic changes that lead to changes in GI peptides. In addition, the ileal pouch epithelium responds to a wide variety of stimuli by adjusting its cellularity and function. These adaptive mechanisms involve systemic factors, such as humoral and neural stimuli, as well as local factors, such as changes in intestinal peristalsis and intraluminal nutrients. There have been conflicting reports as to whether the alterations in GI hormones after RPC have actual clinical implications. What the studies on alterations of GI peptides' response and behavior after RPC have contributed, however, is a window into the possible etiology of complications after pouch surgery, such as pouchitis and malabsorption. Given the possibility of pharmacologically modifying GI peptides or select components of adaptation as a therapeutic strategy for patients with ileal pouch dysfunction or pouchitis, a clear understanding of human pouch mucosal adaptation is of paramount importance. In this review, we summarize the evolution of the RPC and its effects on the GI hormones as well as their possible clinical implications.

Elective and emergent operative management of ulcerative colitis

Surgical therapy of ulcerative colitis is effective, safe, and provides an improved quality of life in those whose disease cannot be managed medically. In the elective setting, widespread acceptance of restorative proctocolectomy has made surgical therapy an attractive option in the overall management of ulcerative colitis. Enthusiasm for this procedure should be tempered by the acknowledgment of the significant incidence of pouchitis in the long term, however. Proctocolectomy with ileostomy remains a good surgical option for patients who are unsuitable for restorative procedures. The standard therapy for fulminant colitis or toxic megacolon remains subtotal colectomy with ileostomy. Patients undergoing subtotal colectomy are candidates for conversion to restorative procedures.

Psychological treatment may reduce the need for healthcare in patients with Crohn's disease

BACKGROUND

Few published studies examine the influence of psychological treatment on health care utilization in Crohn's disease.

METHODS

The present substudy of a prospective, randomized, multicenter trial conducted in 69 of 488 consecutive Crohn's disease (CD) patients was designed to investigate the way in which healthcare utilization is influenced by psychotherapy and relaxation in addition to standardized glucocorticoid therapy. Before and after a 1-year period of standardized somatic treatment the psychotherapy and control groups were compared with regard to hospital and sick-leave days. Predictors of healthcare utilization were analyzed.

RESULTS

The comparison between groups before and after psychological treatment showed a significantly higher decrease of mean hospital days (P < 0.03) and sick-leave days in the treatment group compared with the controls. When a covariate analysis was applied to compare the data at randomization, the difference in hospital days remained statistically a trend (P < 0.1). Multivariate regression analysis detected a significant gender and depression effect for hospital days (cor r(2) = 0.114) and a significant gender and age effect for sick-leave days (cor r(2) = 0.112).

CONCLUSION

A significant drop in healthcare utilization after psychological treatment demonstrates a clear benefit of this additional therapy. This is important, since the study failed to demonstrate significant changes in the psychosocial status or somatic course of study patients. Clinical and psychological factors influencing these outcomes are discussed.

Rod in loop ileostomy: just an insignificant detail for ileostomy-related complications?

BACKGROUND AND AIMS

The aim of this prospective study was to validate a variant in the loop ileostomy construction to reduce peristomal pressure ulcers and, subsequently, the need of stoma therapist assistance and the frequency of changing the stoma appliance.

PATIENTS AND METHODS

We have enrolled 33 consecutive patients who underwent two stage restorative proctocolectomies. The first consecutive 13 patients operated on had their ileostomies constructed with a standard rod. In the following 20 patients, we placed a 5.3-mm suction catheter tube closed with a stitch to form a "ring" and without any stitches fixing it to the skin.

RESULTS

In the "ring" rod group 40% of patients did not report any complication compared to the 8% of patients in the standard rod group (p = 0.046). Pressure ulcers were absent in this group, while it affected 61% of the patients in the standard rod group (p < 0.001). Patients in the "ring" rod group needed significantly less assistance time by the stoma therapist (p < 0.01) and required significantly fewer stoma appliance changes (p < 0.01). In our institution, the overall cost for the complete management of a standard rod ileostomy was 73.16 (29.83-130.49) euro compared to 46.65 (23.15-93.48) euro for a "ring" rod ileostomy (p = 0.002).

CONCLUSIONS

The adoption of a "ring" rod configuration led to an elimination of pressure ulcers due to the rigid rod, a shorter time requirement for stoma care and a decreased number of appliances required and was subsequently associated with lower costs of assistance. A tighter fitting around the ileostomy that avoided stool infiltration improved the practical management of the stoma with a "ring" rod.

Serum biochemical evaluation of patients with functional pouches ten to 20 years after restorative proctocolectomy

BACKGROUND

Restorative proctocolectomy with an ileal pouch-anal anastomosis is a surgical treatment of choice for ulcerative colitis and familial adenomatous polyposis (FAP). Pouchitis is a significant enigmatic morbidity. In the long-term, these patients, we anticipated, would experience biochemical profiling alterations after years of retaining functionally acceptable pouches. This pilot study was aimed at assessing results of essential biochemical variables more than 10 years after surgery.

METHODS

The investigation was carried out in 91 patients; 39 were women. Eight-eight had ulcerative colitis, while three had FAPs. The hand-sewn ileal reservoirs after mucoso-proctocolectomy were 66 S and 25 J. The analyses were compared short-term vs long-term. Patients were investigated and were their own control.

RESULTS

Long-term, incidence of acute and chronic pouchitis was 2 and 13%. Eleven and 4% of patients had hypomagnesaemia and hypocalcaemia. Mean levels were significantly enhanced (p<0.01 and p<0.0002). Hypomagnesaemia corresponded to episodes of pouchitis and was corrected with oral magnesium and antibiotics. Hypoferric anaemia was diagnosed in 7% and treated with oral iron tablets. Chronic pouchitis and recurrent pouch mucosa bleeding were the cause. Hypohemoglobinemia and hypocyanocobalaminemia were noted in 5% and 5%, respectively. Erythrocyte sedimentation rate and white blood cells were supra-normal in 13 and 10%, which corresponded with pouchitis. A significant (p<0.03) steady rise of mean serum immunoglobulin G without correlation to pouchitis was noted.

CONCLUSION

Long-term functional results did not deteriorate. Pouchitis was a significant enigmatic morbidity. Severe or chronic pouchitis complicated hypoferric and vitamin B(12) anemia and hypomagnesaemia.

Practice parameters for the surgical treatment of ulcerative colitis

The American Society of Colon and Rectal Surgeons is dedicated to assuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Persistence of high CD40 and CD40L expression after restorative proctocolectomy for ulcerative colitis

AIM: To focus on the role of CD40 and CD40L in their pathogenesis.

METHODS: We analyzed by immunohistochemistry the CD40 and CD40L expression in the pouch mucosa of 28 patients who had undergone RPC for UC, in the terminal ileum of 6 patients with UC and 11 healthy subjects. We also examined by flow cytometry the expression of CD40 by B lymphocytes and monocytes in the peripheral blood of 20 pouch patients, 15 UC patients and 11 healthy controls.

RESULTS: Ileal pouch mucosa leukocytes presented a significantly higher expression of CD40 and CD40L as compared to controls. This alteration correlated with pouchitis, but was also present in the healthy pouch and in the terminal ileum of UC patients. CD40 expression of peripheral B lymphocytes was significantly higher in patients with UC and pouch, respect to controls. Increased CD40 levels in blood B cells of pouch patients correlated with the presence of spondyloarthropathy, but not with pouchitis, or inflammatory indices.

CONCLUSION: High CD40 expression in the ileal pouch mucosa could be implied in the pathogenesis of pouchitis following proctocolectomy for UC, whereas its increased levels on peripheral blood B lymphocytes are associated with the presence of extraintestinal manifestations.

Mental disorder and psychologic distress in patients with ulcerative colitis after ileal pouch-anal anastomosis

PURPOSE

The aim of this study was to determine if ileal pouch-anal anastomosis in patients with ulcerative colitis is a psychologic burden for patients, the frequency of mental disorders, the amount of psychologic distress, and their possible disease-related determinants. These factors were studied in patients with ulcerative colitis after ileal pouch anal anastomosis and were compared with ulcerative colitis patients without ileal pouch-anal anastomosis and the general German population.

METHODS

A total of 37 patients with ulcerative colitis after ileal pouch-anal anastomosis (age 46.8 +/- 11.8 years; 35 percent female) and 62 patients with ulcerative colitis without ileal pouch-anal anastomosis (age 44.4 +/- 13.9 years; 37 percent female) completed the following questionnaires: medical and sociodemographic questionnaire of the German Competence Network "Inflammatory Bowel Diseases" and the German version of the Hospital Anxiety and Depression Scale. Disease activity was measured in patients with ileal pouch-anal anastomosis by the Pouch Disease Activity Index and in patients without ileal pouch-anal anastomosis by the German Inflammatory Bowel Disease Activity Index. Psychologic distress was assessed by the subscale scores of the Hospital Anxiety and Depression Scale. A probable mental disorder was identified if a patient scored 11 or higher in at least one subscale of the Hospital Anxiety and Depression Scale.

RESULTS

The frequency of a probable psychiatric disorder in patients with ileal pouch-anal anastomosis (16 percent) and without ileal pouch-anal anastomosis (23 percent) did not differ from that in the general German population (17 percent). Ulcerative colitis patients with or without ileal pouch-anal anastomosis did not differ in the amount of psychologic distress. Ileal pouch-anal anastomosis patients had higher levels of anxiety than the general population (P < 0.01). Regression models of disease-related factors predicting mental disorder and psychologic distress showed no significant results.

CONCLUSIONS

Ileal pouch-anal anastomosis neither increases nor decreases the frequency of mental disorders or the amount of psychologic distress in ulcerative colitis patients.