A longitudinal study of long-term quality of life after ileal pouch-anal anastomosis

DECIDE: Delphi Expert Consensus Statement on Inflammatory Bowel Disease Dysplasia Shared Management Decision-Making

BACKGROUND AND AIMS

Inflammatory bowel disease colitis-associated dysplasia is managed with either enhanced surveillance and endoscopic resection or prophylactic surgery. The rate of progression to cancer after a dysplasia diagnosis remains uncertain in many cases and patients have high thresholds for accepting proctocolectomy. Individualised discussion of management options is encouraged to take place between patients and their multidisciplinary teams for best outcomes. We aimed to develop a toolkit to support a structured, multidisciplinary and shared decision-making approach to discussions about dysplasia management options between clinicians and their patients.

METHODS

Evidence from systematic literature reviews, mixed-methods studies conducted with key stakeholders, and decision-making expert recommendations were consolidated to draft consensus statements by the DECIDE steering group. These were then subjected to an international, multidisciplinary modified electronic Delphi process until an a priori threshold of 80% agreement was achieved to establish consensus for each statement.

RESULTS

In all, 31 members [15 gastroenterologists, 14 colorectal surgeons and two nurse specialists] from nine countries formed the Delphi panel. We present the 18 consensus statements generated after two iterative rounds of anonymous voting.

CONCLUSIONS

By consolidating evidence for best practice using literature review and key stakeholder and decision-making expert consultation, we have developed international consensus recommendations to support health care professionals counselling patients on the management of high cancer risk colitis-associated dysplasia. The final toolkit includes clinician and patient decision aids to facilitate shared decision-making.

Infliximab versus ciclosporin in steroid resistant acute severe ulcerative colitis: a model-based cost-utility analysis of data from CONSTRUCT pragmatic trial

BACKGROUND

There is limited evidence in the literature on the long-term effectiveness and cost-effectiveness of treatments for Acute Severe Ulcerative Colitis (ASUC). The study aimed to perform decision analytic model-based long-term cost-utility analysis (CUA) of infliximab versus ciclosporin for steroid-resistant ASUC investigated in CONSTRUCT pragmatic trial.

METHODS

A decision tree (DT) model was developed using two-year health effect, resource use and costs data from CONSTRUCT trial to estimate relative cost-effectiveness of two competing drugs from the United Kingdom (UK) National Health Services (NHS) perspective. Using short-term trial data, a Markov model (MM) was then developed and evaluated over further 18 years. Both DT and MM were combined to investigate cost-effectiveness of infliximab versus ciclosporin for ASUC patients over 20-year time horizon, with a rigorous multiple deterministic and probabilistic sensitivity analyses to address uncertainty in results.

RESULTS

The decision tree mirrored trial-based results. Beyond 2-year trial follow-up, Markov model predicted a decrease in colectomy rate, but it remained slightly higher for ciclosporin. NHS costs and quality adjusted life years (QALYs) over base-case 20 year time horizon were £26,793 and 9.816 for ciclosporin and £34,185 and 9.106 for infliximab, suggesting ciclosporin dominates infliximab. Ciclosporin had 95% probability of being cost-effective at a willingness-to-pay (WTP) threshold value up to £20,000.

CONCLUSION

Using data from a pragmatic RCT, the cost-effectiveness models produced incremental net health benefit in favour of ciclosporin relative to infliximab. Results from long-term modelling indicated that ciclosporin remains dominant compared with infliximab for the treatment of NHS ASUC patients, however, these need to be interpreted cautiously.

TRIAL REGISTRATION

CONSTRUCT Trial registration number ISRCTN22663589; EudraCT number: 2008- 001968-36 (Date 27/08/2008).

Quality of Life in Patients with Acute Severe Ulcerative Colitis: Long-Term Follow-Up Results from the CONSTRUCT Trial

BACKGROUND

there is currently limited research examining the QoL of patients with Ulcerative colitis (UC) following treatment of acute severe colitis (ASUC).

OBJECTIVE

to examine the long-term QoL of ASUC patients enrolled in the CONSTRUCT trial following treatment of UC with infliximab or ciclosporin and to compare the differences in the QoL between the two drug treatments over time.

METHODS

The CONSTRUCT trial examined the cost and clinical effectiveness of infliximab and ciclosporin treatments for acute severe UC. We collected QoL questionnaire data from patients during the active trial period up to 36 months. Following trial completion, we contacted patients postannually for up to a maximum of 84 months. We collected QoL data using a disease-specific (CUCQ, or CUCQ+ for patients who had colectomy surgery) or generic (EQ5D-3L) questionnaire. We analysed QoL scores to determine if there was any difference over time and between treatments in generic or disease-specific QoL.

RESULTS

Following initial treatment with infliximab and ciclosporin, patients experienced a statistically significant improvement in both the generic and disease-specific QoL at three months. Generic scores remained fairly static for the whole follow-up period, reducing only slightly up to 84 months. Disease-specific scores showed a much sharper improvement up to 2 years with a gradual reduction in QoL up to 84 months. Generic and disease-specific QoL remained higher than baseline values. There was no significant difference between treatments in any of the QoL scores.

CONCLUSIONS

Both infliximab and ciclosporin improve QoL following initial treatment for ASUC. QoL scores remain higher than at admission up to 84 months post-treatment.

Pouch Function Over Time and With Advancing Age

BACKGROUND

No long-term pouch studies have included follow-up >30 years or an analysis in patients >80 years old.

OBJECTIVE

This study aimed to investigate pouch function and pouch failure in patients with a pouch in situ >30 years and in patients >80 years old.

DESIGN

This is a retrospective review.

SETTING

This study was conducted at an IBD referral center.

PATIENTS

Adult patients with ulcerative colitis who underwent an IPAA between 1983 and 1990 were selected.

MAIN OUTCOME MEASURES

The primary outcomes measured were pouch function and pouch failure rates.

METHODS

Data collection included diagnosis, age at IPAA, indication for IPAA, medications at IPAA, pathology at the time of IPAA, postoperative morbidity, functional outcomes, quality of life, pouch excision or ileostomy and indication, and date of last follow-up. All living patients were contacted in April 2020 to retrieve functional data and pouch failure rates.

RESULTS

A total of 566 patients had a pouch constructed between 1983 and 1990; of the 145 at most recent contact, 75 had their pouch in situ ≥30 years and 14 were ≥80 years old. Mean age at diagnosis was 25.8 years (10.6 SD), age at surgery was 34.7 years (11.3 SD), and age at last follow-up was 60.5 years (13.2 SD). At a median of 30 years (IQR, 21-32), 145 patients responded to the functional survey. Significantly increased rates of urgency (always, mostly, sometimes: 71.5% vs 23.5%) and seepage during the day (71.4% vs 22.4%) were observed in patients ≥80 years. In patients ≥80 years with a pouch in situ ≥30 years, urgency and incontinence were sometimes experienced by nearly 50% and pouch failure occurred in one third of patients. The overall rate of pouch failure was 19.4% (n = 110) at a median follow-up of 15 years; risk factors were female sex, 3-stage approach, and pelvic sepsis.

LIMITATIONS

A retrospective database was used.

CONCLUSION

Patients with IPAA maintain good pouch function even after 30 years and in patients over the age of 80 years. Pouch function declines with time and failure rates increase over time. See Video Abstract at http://links.lww.com/DCR/B684.Función De La Bolsa Ileal En El Tiempo Y En Pacientes De Edad Avanzada.

ANTECEDENTES

No se han efectuado estudios en pacientes con bolsa a largo plazo que incluyan un seguimiento por treinta años o más y en pacientes mayores de 80 años.

OBJETIVO

Investigar la funcionalidad o la falla de la bolsa en pacientes bolsa in situ por mas de treinta años y en pacientes mayors de 80 años.

DISEO

Revisión retrospective.

ESCENARIO

Centro de referencia de Enfermedad Inflamatoria Intestinal.

PACIENTES

Pacientes adultos con diagnóstico de colitis ulcerative sometidos a anastomosis bolsa ileal anal (IPAA) entre 1983 y 1990.

PRINCIPALES PARAMETROS DE RESULTADOS

Indices de efectividad y disfunción de la bolsa ileal.

METODOS

Recopilación de la información incluyendo diagnóstico, edad del procedimiento (IPAA), indicaciones para IPAA, medicamentos para IPAA, patología en el transcurso del IPAA, morbilidad postoperatoria, resultados funcionales, calidad de vida, excisión de la bolsa o ileostomía y su indicación y fecha de seguimiento mas reciente. Se contactaron a todos los pacientes vivos en abril de 202 para recuperar la información de los índices de funcionalidad o disfunción de la bolsa.

RESULTADOS

Se les construyó una bolsa a un total de 566 pacientes entre 1983 y 1990; de los 145 mas recientemente contactados, 75 permanecían con su bolsa in situ ≥ 30 años y 14 eran mayores de 80 años. La edad media en el momento de diagnóstico fue de 25.8 años (con desviación estándar de 10.6, sd), edad al momento de la cirugía fue de 34.7 años (11.3sd), y la edad en el último seguimiento de 60.5 años (13.2,sd). A una media de 30 años (IQR: 21,32), 145 pacientes respondieron al cuestionario de funcionalidad. En pacientes mayores de 80 años se observaron tasas aumentadas de urgencia (siempre, la mayor parte de las veces, algunas veces: 71.5% vs 23.5%) y fuga durante el día (71.4% versus 22.4%). En pacientes mayores de 80 años con una bolsa in situ durante 30 años o más, experimentaron urgencia e incontinencia en cerca del 50% y disfunción de la bolsa en un tercio de los pacientes. La tasa global de fallo de la bolsa fue de 19.4% (n = 110) en un seguimiento a 15 años; los factores de riesgo asociados fueron: sexo femenino, abordaje de tres tiempos y sepsis pélvica.

LIMITACIONES

Información retrospective.

CONCLUSIONES

Los pacientes con IPAA continúan con una función adecuada de la bolsa aún después de 30 años de efectuada así como en pacientes mayores de 80 años. La funcionalidad de la bolsa disminuye con el tiempo y las tasa de falla aumentan de igual forma con el tiempo. Consulte Video Resumen en http://links.lww.com/DCR/B684. (Traducción- Dr. Miguel Esquivel-Herrera).

Cap polyposis treated with laparoscopic-assisted total proctocolectomy and ileal J-pouch anal anastomosis: a case report

Background

Cap polyposis (CP) is extremely rare in Japan, and there is no established cure. We report a case in which CP was improved by surgical treatment.

Case presentation

A 48-year-old man was investigated at a local hospital because of diarrhea and bloody stools in 2018. The patient was treated with metronidazole for suspected amoebic dysentery, but his symptoms did not improve. Subsequent close examination revealed possible CP, but treatment with 5-aminosalicylic acid and a steroid enema had no effect. The patient was then referred to our hospital. The bloody stools, diarrhea, and abdominal pain worsened despite medical treatment, so laparoscopic-assisted total proctocolectomy and ileal J-pouch anal anastomosis with ileostomy were performed. CP has no known cause or established treatment, but Helicobacter pylori (HP) infection has been reported in many CP cases in Japan, and HP eradication is often successful. This patient was HP-negative and did not improve with antimicrobial treatment, but the symptoms improved after surgery.

Conclusions

Even after surgery, CP recurrence reportedly occurs within a short period in many cases. However, our patient has had no signs of CP recurrence during 1 year of follow-up.

IPAA in Known Preoperative Crohn's Disease: A Systematic Review

BACKGROUND

Crohn's disease is a relative contraindication to IPAA due to perceived increased rates of pouch failure.

OBJECTIVE

This study aimed to determine pouch functional outcomes and failure rates in patients with a known preoperative diagnosis of Crohn's disease.

DATA SOURCES

A database search was performed in Ovid Medline In-Process & Other NonIndexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, and Ovid Cochrane Database of Systematic Reviews.

STUDY SELECTION

The published human studies that reported short-term postoperative outcomes and/or long-term outcomes following IPAA in adult (≥18 years of age) Crohn's disease populations were selected.

INTERVENTION

Ileal pouch anal anastomoses were constructed in patients who had Crohn's disease diagnosed preoperatively or through proctocolectomy pathology.

MAIN OUTCOMES MEASURES

The primary outcomes measured were long-term functional outcomes (to maximal date of follow-up) and the pouch failure rate.

RESULTS

Of 7019 records reviewed, 6 full articles were included in the analysis. Rates of pelvic sepsis, small-bowel obstruction, pouchitis, anal stricture, and chronic sinus tract were 13%, 3%, 31%, 18%, and 28%. Rates of incontinence, urgency, pad usage in the day, pad usage at night, and need for antidiarrheals were 24%, 21%, 19%, 20%, and 28%, and mean 24-hour stool frequency was 6.3 bowel movements at a mean 69 months of follow-up. The overall pouch failure rate was 15%; no risk factors for pouch failure were identified.

LIMITATIONS

This investigation was limited by the small number of studies with significant study heterogeneity.

CONCLUSION

In patients with known preoperative Crohn's disease, IPAA construction is feasible with functional outcomes equivalent to patients with ulcerative colitis, but, even in highly selected patients with Crohn's disease, pouch failure rates remain higher than in patients with ulcerative colitis.

[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.

Experience, complications and prognostic factors of the ileoanal pouch in ulcerative colitis: An observational study

INTRODUCTION

Ileoanal pouch following restorative proctocolectomy is the treatment for ulcerative colitis after failed medical treatment. Our main aim was to evaluate early and late morbidity associated with restorative proctocolectomy. The secondary aim was to assess risk factors for pouch failure.

METHODS

A retrospective, observational, single-center study was performed. Patients who had undergone restorative proctocolectomy for a preoperative diagnosis of ulcerative colitis from 1983-2015 were included. Early (<30 days) and late (>30 days) adverse events were analyzed. Pouch failure was defined as the need for pouch excision or when ileostomy closure could not be performed. Univariate and multivariate analyses were performed to assess pouch failure risk factors.

RESULTS

The study included 139 patients. One patient subsequently died in the early postoperative period. Mean follow-up was 23 years. Manual anastomoses were performed in 54 patients (39%). Early adverse events were found in 44 patients (32%), 15 of which (11%) had anastomotic fistula. Late adverse events were found in 90 patients (65%), and pouch-related fistulae (29%) were the most commonly found in this group. Pouch failure was identified in 42 patients (32%). In the multivariate analysis, age >50 years (p<0.01; HR: 5.55), handsewn anastomosis (p<0.01; HR: 3.78), pouch-vaginal (p=0.02; HR: 2.86), pelvic (p<0.01; HR: 5.17) and cutaneous p=0.01; HR: 3.01) fistulae were the main pouch failure risk factors.

CONCLUSION

Restorative proctocolectomy for a preoperative diagnosis of ulcerative colitis has high morbidity rates. Long-term outcomes could be improved if risk factors for failure are avoided.

Short- and Long-term Outcomes After Ileal Pouch Anal Anastomosis in Pediatric Patients: A Systematic Review

BACKGROUND

Restorative proctocolectomy and ileal pouch anal anastomosis (IPAA) has become the procedures of choice for restoration of intestinal continuity in ulcerative colitis or familial adenomatous polyposis. This systematic review aims to assess short-term postoperative and long-term functional outcomes in pediatric patients undergoing IPAA.

METHODS

A literature search was performed for all publications of pediatric IPAA in which short- and long-term outcomes were reported. Papers were excluded based on title, abstract, and full-length review. Data collection included patient demographics, medication use preoperatively, operative approach, 30-day postoperative outcomes, long-term functional outcomes (to maximal date of follow-up), and pouch failure rate. Outcomes were compared in those patients with and without perioperative corticosteroid exposure. Study quality and risk of bias was assessed using the Newcastle-Ottawa Scale as all studies were cohort studies.

RESULTS

Of 710 records reviewed, 42 full papers were included in the analysis. Rates of superficial surgical site infection, pelvic sepsis, ileus, and small bowel obstruction at <30 days were 10%, 11%, 10%, and 14%, respectively. Rates of pouchitis, stricture, chronic fistula tract, incontinence, and pouch failure were 30%, 17%, 12%, 20%, and 8%, respectively, at 37-109 months of follow-up; incontinence was significantly higher in those exposed to corticosteroids preoperatively (52% vs 20%; P < 0.001). The median daytime, nighttime, and 24-hour stool frequency were 5.3, 1.4, and 5 bowel movements, respectively.

CONCLUSIONS

IPAA is safe with good long-term functional outcomes in pediatric patients.

Complications in children with ulcerative colitis undergoing ileal pouch-anal anastomosis

Total colectomy with ileal pouch-anal anastomosis (IPAA) is considered the standard procedure for the surgical management of ulcerative colitis. Despite the widespread utility of the procedure, as many as 75% of patients who undergo IPAA, experience at least 1 complication. This review highlights difficult intraoperative scenarios and complications of pouch surgery in children, including intraoperative, postoperative, and functional complications. Intraoperative scenarios include insufficient mesenteric length and positive leak tests. Postoperative complications include surgical site infection, anastomotic leak, stricture, fistula, pouchitis, small bowel obstruction, and pouch failure. Less common complications include afferent limb syndrome, pouch prolapse, and superior mesenteric artery syndrome. Functional complications include incontinence, impaired quality of life, infertility, and sexual dysfunction. Despite complications, most patients are satisfied with their outcomes and report an improvement in their lifestyle.

Results at Up to 30 Years After Ileal Pouch-Anal Anastomosis for Chronic Ulcerative Colitis

BACKGROUND

Ileal pouch-anal anastomosis (IPAA) has become the surgical procedure of choice for patients with chronic ulcerative colitis. No study to date has examined functional and quality-of-life outcomes 30 years after pouch construction.

METHODS

Using data from a prospectively maintained database with annually distributed questionnaires, functional outcomes, pouch complications, and quality of life after IPAA were determined.

RESULTS

Overall, 93.3% of patients had a functioning pouch at 30 years. Stool frequency during the day increased slightly from a mean of 5.7 (SD, 2.3) at 1 year to 6.2 (SD, 2.9) at 30 years (P < 0.001); nighttime frequency also increased slightly from 1.5 (SD, 1.2) to 2.1 (SD, 1.2) (P < 0.001). Pouch outcomes and stool frequency were significantly associated with diagnosis, being worse in patients with Crohn's disease, but were minimally associated with age greater than 65 years. After IPAA, the 30-year cumulative probability of pouchitis, stricture, obstruction, and fistula were 80.2%, 56.7%, 44.0%, and 15.8%, respectively. Quality of life scores remained stable over the 30 years.

CONCLUSIONS

IPAA is a durable operation for patients requiring proctocolectomy for chronic ulcerative colitis and indeterminate colitis. The functional outcomes and quality of life remained relatively unchanged over the 30 years after IPAA underscoring the longevity of pouches.

A comparison of the quality of life of ulcerative colitis patients after IPAA vs ileostomy

BACKGROUND

Total proctocolectomy with IPAA is frequently considered the procedure of choice for surgical patients with ulcerative colitis, presumably owing to an expectation of improved quality of life in comparison with an ileostomy.

OBJECTIVE

The goal of our study was to determine whether long-term quality of life among patients with a pelvic pouch is better than those who chose a permanent stoma.

DESIGN

This investigation is a cross-sectional observational study using a prospective database.

SETTING

This study was conducted at an academic medical center.

PATIENTS

Consecutive patients who had undergone IPAA or a permanent ileostomy for ulcerative colitis by a single surgeon, presenting for their annual follow-up visit from July through September 2011, were offered participation in the study. A randomly chosen group of subjects who did not have scheduled appointments during the study period were sent a letter inviting them to participate in the study.

MAIN OUTCOME MEASURES

The primary outcome measures used were EQ-5D-3L, the Short Quality of Life in Inflammatory Bowel Disease questionnaire, the Cleveland Global Quality of Life instrument, the Fecal Incontinence Quality of Life scale, and the Stoma Quality of Life scale.

RESULTS

Thirty-five patients with a pelvic pouch and 24 ostomates were accrued and comprehensively studied. Global quality-of-life scores were virtually identical for the 2 groups. Patients with a pelvic pouch had better subscores in current quality of health and energy level, Fazio score, sexuality/body image, and work/social function.

LIMITATIONS

This study was limited by its small sample size, and some of our patients were enrolled through mailed surveys and, hence, nonresponse bias may be present. The follow-up time since surgery was longer in the pelvic pouch group than in the ileostomy group.

CONCLUSION

Informed patients with ulcerative colitis choosing an ileostomy have a health-related global quality of life very similar to patients with a pelvic pouch. Better outcomes in patients with an ileal pouch were most evident in the areas of sexuality/body image and work/social function.

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.

Influence of age at ileoanal pouch creation on long-term changes in functional outcomes

AIM

We reviewed the functional results and quality of life (QOL) of patients who had had an ileoanal pouch (IPAA) for at least 15 years.

METHOD

Retrospective analysis was undertaken of data accrued prospectively into a pouch database since 1983. Patients who had retained an IPAA for at least 15 years were identified. Trends in IPAA function and QOL of the patients were determined over a time-period of 15 years after formation of the IPAA. Data were compared for patients who were < 35, 35-55 and > 55 years of age when the IPAA was formed.

RESULTS

Three hundred and ninety-six of a total of 3276 patients in the database (53% men, median age 36 years and median follow-up 17.1 years) underwent IPAA with at least 15 years of follow-up. The final pathology was ulcerative colitis in 78%; 66.4% of patients had a restorative proctocolectomy, 91.4% underwent temporary diversion, 59% had a J-pouch configuration and 63.1% a stapled anastomosis. The frequency of bowel movements remained the same over the follow-up period. There was an increase in the incidence of incontinence and urgency after 15 years with no significant change in dietary, social, work and sexual restrictions during follow-up. Patients in all three age groups experienced deterioration in pouch function at 15 years of follow up compared with the function at 5 years. The QOL of the patients remained high and stable.

CONCLUSION

There is a deterioration of pouch function after 15 years, irrespective of the age of the patient when the IPAA was formed. Despite this, QOL appears to be high for all patients who retain their pouch.

A longitudinal study of quality of life and functional outcome of patients with ulcerative colitis after proctocolectomy with ileal pouch-anal anastomosis

PURPOSE

Ileal pouch-anal anastomosis is considered the surgical treatment of choice for patients with ulcerative colitis. It is safe and effective but associated with long-term complications, making functional outcome and quality of life important factors in determining patient outcome. Longitudinal studies on long-term functional outcome and quality of life are sparse. The purpose of this study was to longitudinally evaluate the long-term functional outcome and quality of life of ulcerative colitis patients who underwent proctocolectomy with ileal pouch-anal anastomosis.

METHODS

The study group was composed of ulcerative colitis patients who underwent pouch operation in our institution between 1990 and 2001 who had filled in quality of life and functional outcome questionnaires 60 months (mean) after ileostomy closure and responded to the same questionnaires at 133 months (mean) after ileostomy closure. They served as their own controls. Quality of life was scored using the Medical Outcomes Study Short Form 36. Global Assessment of Functioning Scale was used to evaluate functional outcome.

RESULTS

Data were obtained for 63 of the 77 patients (82%) who had answered the first questionnaire. The mean interval between responding to the 2 questionnaires was 73 +/- 3 months. Functional outcome did not deteriorate over time. Some quality of life scores (bodily pain, general health perception, and the physical component summary) worsened over time, whereas the other scales of the Short Form 36 scores did not change.

CONCLUSION

The functional outcome of ulcerative colitis patients after a pouch operation did not change significantly over time. The overall quality of life was generally stable, however, some aspects did deteriorate over time. These findings merit further investigation.

Medical decision analysis for the management of unifocal, flat, low-grade dysplasia in ulcerative colitis

BACKGROUND

Management of unifocal, flat, low-grade dysplasia (LGD) in ulcerative colitis (UC) remains controversial.

OBJECTIVE

To compare the relative costs and effectiveness of immediate colectomy and enhanced colonoscopic surveillance for the management of LGD.

DESIGN AND SETTING

Medical decision analysis by using state-transition Markov models. Transition probabilities and health utilities were derived from the literature, and costs were derived from national hospital data sets and Medicare and/or Medicaid reimbursement schedules.

PATIENTS

Two simulated cohorts of 10,000 patients with longstanding UC who were newly diagnosed with unifocal, flat LGD on initial surveillance colonoscopy.

INTERVENTIONS

Immediate colectomy or enhanced surveillance (repeated colonoscopy at 3, 6, and 12 months, and then annually).

MAIN OUTCOME MEASUREMENTS

Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.

RESULTS

Immediate colectomy dominated over enhanced surveillance and yielded higher QALYs (20.1 vs 19.9 years) and lower costs ($75,900 vs $83,900). These findings were robust to variations in model parameters, with immediate colectomy remaining dominant in 90% of simulations in sensitivity analysis. Varying postcolectomy health utility outside the range in the probabilistic sensitivity analysis rendered enhanced surveillance cost effective. When the health utility was below 0.77, the incremental cost-effectiveness ratio was $50,000 per QALY.

LIMITATIONS

Data based on observational studies and analyses rely on model assumptions.

CONCLUSIONS

Our analysis showed that immediate colectomy was preferable to enhanced surveillance. Health preference toward the postcolectomy state is, however, an influential factor. This decision analysis model provides a conceptual framework for physicians and patients to understand the relative benefits and costs of both interventions.

Prevalence and outcome of anemia after restorative proctocolectomy: a clinical literature review

PURPOSE

Iron and/or vitamin B12 deficiency anemias, which have adverse effects on patients' quality of life, are commonly observed and often overlooked complications after restorative proctocolectomy. We performed a systematic review of publications on the prevalence of anemia as well as on the impact of anemia on a range of clinical, functional, quality of life, and economic outcomes in restorative proctocolectomy patients. This information is important to help healthcare providers through a comprehensive overview to increase awareness about a condition that could require therapy to improve patient healthcare and quality of life.

METHODS

We reviewed the English language publications on the incidence of anemia and its adverse effect after restorative proctocolectomy The United States National Library of Medicine database (MEDLINE), the Excerpta Medica database (EMBASE), the Cochran Library, and the Google search engine were searched for published articles on the prevalence and impact of anemia in post-restorative proctocolectomy surgical patients.

RESULTS

The long-term complication most frequently described after RPC is pouchitis. Pouchitis is significantly associated with iron deficiency anemia caused by pouch mucosal bleeding. Other causes are insufficient and/or impaired iron absorption. It has also been observed, however, that restorative proctocolectomy patients with underlying familial adenomatous polyposis rarely develop pouchitis yet show higher rates of iron deficiency anemia compared to those patients with underlying ulcerative colitis. Other causes shown as independent risk factors for iron deficiency anemia in restorative proctocolectomy patients are malignancy, desmoid tumors, and J-pouch configuration. Vitamin B12 deficiency anemia is also common after restorative proctocolectomy. About one-third of restorative proctocolectomy patients show abnormal Schilling test and 5 percent have low referenced serum cobalamin. It has been observed that the degree resection of the terminal-ileum, malabsorption, bacterial overgrowth, and dietary factors are among the known causes of cobalamin deficiency. Folate deficiency has not been reported in restorative proctocolectomy patients. Describing restorative proctocolectomy surgery and its outcomes, in patients without anemia, the quality of life is reported excellent regardless of operative technique.

CONCLUSIONS

Anemia is not uncommon following restorative proctocolectomy and has been shown to have negative effects on the patient's quality of life and the economy and may substantially increase healthcare costs. The treatment of anemia and its underlying causes is important to improving clinical and economic outcomes.

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.

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

BACKGROUND

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

METHODS

Using data from a prospective database and annual standardized questionnaires, functional outcome, complications and quality of life (QoL) after IPAA were assessed.

RESULTS

Some 1885 IPAA operations were performed for chronic ulcerative colitis over a 20-year period (mean follow-up 11 years). The mean age at the time of IPAA was 34.1 years, increasing from 31.2 years (1981-1985) to 36.3 years (1996-2000). The overall rate of pouch success at 5, 10, 15 and 20 years was 96.3, 93.3, 92.4 and 92.1 per cent respectively. Mean daytime stool frequency increased from 5.7 at 1 year to 6.4 at 20 years (P < 0.001), and also increased at night (from 1.5 to 2.0; P < 0.001). The incidence of frequent daytime faecal incontinence increased from 5 to 11 per cent during the day (P < 0.001) and from 12 to 21 per cent at night (P < 0.001). QoL remained unchanged and 92 per cent remained in the same employment. Seventy-six patients were eventually diagnosed with indeterminate colitis and 47 with Crohn's disease.

CONCLUSION

IPAA is a reliable surgical procedure for patients requiring proctocolectomy for chronic ulcerative colitis and indeterminate colitis. The clinical and functional outcomes are excellent and stable for 20 years after operation.

Psychological distress and functional impairment in patients with personality disorders

The study is aimed at investigating the impact of a personality disorder (PD) diagnosis, in terms of functional impairment and subjective distress, in order to better understand the burden of this diagnosis and its implications. Among the 462 consecutive psychiatric patients diagnosed with the DSM structured interview for Axis I, II and V diagnoses, almost 60% had PD. Patients with PD displayed considerable vulnerability and suffering in many domains, including finances and interpersonal relationships. Despite the educational and occupational similarities of PD patients and non-PD patients, the PD patients had more problems maintaining permanent job positions. They also had more symptomatic suffering and concerns about health than non-PD patients. Generally, the results were in line with findings in the literature but more thoroughly captured the challenges that PD patients face in various areas of life. Awareness of the frequent comorbidity of PD with Axis I disorders seems crucial in developing future treatment plans with an emphasis on psychosocial rehabilitation, vocational training and social support.

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.

Anal canal pressure after ileal pouch-anal anastomosis with strengthened internal anal sphincter

INTRODUCTION

The aim of sphincter-saving operative techniques and creation of intestinal reservoirs is to improve the quality of life for patients with restorative prococolectomy.

METHODS

In this study, 48 consecutive patients (19 males and 29 females of ages between 19 and 55 years; mean age, 35.52 years) with ulcerative colitis and familial adenomatous polyposis underwent ileal pouch-anal anastomosis after proctocolectomy in 1986 to 2002. In 26 patients (54.17 percent of the cases), 10 males and 16 females, ileal pouch-anal anastomosis was performed after a modified surgical technique for strengthening the internal anal sphincter by creation of a smooth muscle cuff through plication of a mucosectomized segment of residual rectum. Basal resting anal canal pressure and pressure after voluntary contraction were recorded preoperatively, one month after surgery, and every six months for two years.

RESULTS

One month after the operation manometric results showed significantly higher values of resting pressure in patient with a plicated rectal segment than values measured preoperatively (P < 0.001). This effect was absent after the standard ileal pouch-anal anastomosis. With the rectal plication technique, basal pressure increased from a preoperative value of 69 +/- 6 mmHg up to 80 +/- 6 mmHg at the end of the second postoperative year (P < 0.001).

CONCLUSIONS

We concluded that ileal pouch-anal anastomosis with rectal plication perhaps improved sphincter function. The operative technique did not affect anal squeeze pressure. Patients quality of life was improved for those undergoing the modified ileal pouch-anal anastomosis.

The effect of ageing on function and quality of life in ileal pouch patients: a single cohort experience of 409 patients with chronic ulcerative colitis

OBJECTIVE

To evaluate in what manner ageing affects functional outcome and quality of life (QoL) in patients with chronic ulcerative colitis (CUC) after ileal pouch-anal anastomosis (IPAA).

SUMMARY BACKGROUND DATA

Short-term function and QoL after IPAA is good. However, patients are usually young, and little is known about the influence of time and ageing on long-term outcomes after IPAA.

METHODS

Using a standardized questionnaire, functional outcome, QoL, and complications were assessed prospectively in a cohort of 409 patients followed annually for 15 years after IPAA.

RESULTS

Follow-up was complete in the single cohort of 409 patients and functional and QoL outcomes summarized at 5, 10, and 15 years. Daytime stool frequency changed little (mean 6), while nighttime frequency increased from 1 stool to 2 stools. Incontinence for gas and stool increased from 1% to 10% during the day and from 2% to 24% at night over 15 years. The cumulative probability of pouchitis increased from 28% at 5 years to 38% at 10 years and to 47% at 15 years. Bowel obstruction and stricture were other principal long-term complications. At 15 years, 91% of patients had kept the same job. Work was not affected by the surgery in 83%, while social activities, sports, traveling, and sexual life all improved after surgery and did not deteriorate over time.

CONCLUSIONS

These long-term results in a single cohort of 409 IPAA patients are unique and are likely a more accurate reflection of long-term outcome than has been previously reported. These data support the conclusion that IPAA is a durable operation for patients requiring proctocolectomy for CUC; functional and QoL outcomes are good, predictable, and stable for 15 years after operation.

Patterns of disease and surgical treatment among United States veterans more than 50 years of age with ulcerative colitis

BACKGROUND

Ulcerative colitis (UC) is a clinical entity that predominantly affects young adults yet large series of middle age or elderly patients with UC are infrequently reported. The aim of this study is to identify patterns of disease, indications for operation, surgical treatment, and outcome of patients more than 50 years of age who required surgery for UC in Department of Veterans Affairs (DVA) Medical Centers.

METHODS

A population-based study on all patients in 159 hospitals of the DVA from 1997 to 2001 was carried out. Data were compiled from several national computerized VA data sets. Supplementary information including demographic information, discharge summaries, operative reports and pathology reports were obtained from local medical records. Patient variables were entered into a computerized database and analyzed using the Pearson chi-square and Fisher's exact tests. Statistical significance is designated as P < 0.05.

RESULTS

One hundred fifty-eight patients were evaluable. The mean age was 59 years (range 51-81); 99% were male. The mean duration of UC was 23 years (range 2 to 50). One hundred of the 158 patients had proctocolitis; 58 had either left-sided colitis or proctosigmoiditis. The mean dose of prednisone prior to surgery was 20 mg; the mean duration of steroid use was 8 years. The indications for elective surgery were intractability (59%), mass or stricture (27%), and dysplasia (14%). Twenty of the 158 patients (12%) were operated on emergently for either toxic colitis, perforation, or hemorrhage. One hundred three of the 158 underwent proctocolectomy and permanent ileostomy, 55 underwent a restorative proctocolectomy, and underwent a segmental colectomy. Twenty of the 158 patients were found to have dysplasia in their colectomy specimens; an additional 10 (7%) were found to have invasive cancer. Surgical morbidity was 22%. Overall mortality was 4% (7 of 158); all but 1 death occurred after emergent surgery. Mean hospitalization was 36 days (range 2 to 297).

CONCLUSIONS

Restorative proctocolectomy was performed in 36% of veterans more than 50 years of age requiring surgery for UC. The majority required surgery for intractable symptoms. Dysplasia and invasive cancer was found in 18% of patients. Mortality after surgery for acute surgical emergencies remains high.