Should older patients undergo ileal pouch-anal anastomosis?

Current Perspectives on Indications for Ileal Pouch-Anal Anastomosis in Older Patients

The population of older patients with inflammatory bowel disease (IBD) is expected to continue to increase in the coming decades, which necessitates and improved understanding of the critical issues faced by patients in this population. Although restorative proctocolectomy with IPAA remains the surgical procedure of choice for the majority of patients with medically refractory ulcerative colitis (UC) and UC-related dysplasia, the evidence surrounding surgery for older patients UC remains sparse. In particular, comparisons of outcomes among older and younger patients undergoing IPAA and comparisons between older patients undergoing IPAA and those undergoing proctocolectomy with end ileostomy remain an understudied and important issue, as evidence in this area will be used to guide patient-centered surgical choices among older patients who require colectomy for UC. In this narrative review, we review the available literature regarding IPAA for older patients, as well as the pre-, peri-, and postoperative factors that may influence outcomes in this population.

Essential updates 2020/2021: Colorectal diseases (benign)—Current topics in the surgical and medical treatment of benign colorectal diseases

The development of new drugs for inflammatory bowel disease (IBD) is remarkable, and treatment strategies using multiple agents and various techniques are required; however, the treatment strategy is likely to be complex. Therefore, appropriate evaluation of traditional surgical treatment strategies and accurate knowledge of the efficacy and limitations of novel treatments are required. Total infectious complications were found to be associated with the use of corticosteroids and anti‐tumor necrosis factor‐α agents, but not with immunomodulators, anti‐integrin agents, and 5‐aminosalicylic acid. Regarding surgical procedures for IBD, conceived anastomosis methods, including Kono‐S for Crohn's disease stenosis, are associated with better outcomes than conventional techniques. Autologous cell transplantation for Crohn's fistulae has been shown to have a favorable outcome. Diverticulitis is increasing and will be treated more frequently in the future. Risk factors for the incidence of diverticulitis and differences in pathogenesis according to right or left side diverticulitis have been reported. Antibiotic therapy may be omitted for uncomplicated diverticulitis. Moreover, regarding surgical procedures, both bowel resection and anastomosis are associated with favorable short‐term outcomes, higher stoma closure rate, and superior medical economy compared to Hartmann's procedure. Risk factors for recurrence after diverticulitis surgery may provide better postoperative follow‐up. In this review, we explore the current topics of colorectal benign diseases, focusing on IBD and diverticulitis, based on clinical trials and meta‐analyses from 2020‐2021. This review consolidates the available knowledge and improves the quality of surgical procedures and perioperative management for IBD and diverticulitis.

Short-Term Outcomes for Restorative and Non-Restorative Proctocolectomy in Older Adults

BACKGROUND

Curative surgery for ulcerative colitis can be subdivided into restorative (with pouch and anastomosis) and non-restorative operations. Restorative surgery in older adults is controversial, due to concerns about surgical risk and long-term functional outcome. The goal of this study is to compare 30-day outcomes for restorative and non-restorative surgery in older adults with ulcerative colitis.

METHODS

Data were obtained from the American College of Surgeons National Surgical Quality Initiative Program from 2012-2018. Patients were included if they were >65 years old and had ulcerative colitis. Restorative and non-restorative surgeries were defined with procedure codes. Patient characteristics and adverse surgical outcomes were compared between restorative and non-restorative surgeries utilizing chi-square tests and Fisher's exact tests. Multivariate logistic regression models were constructed to evaluate the association of restorative versus non-restorative surgery with adverse surgical outcomes while adjusting for potential confounders.

RESULTS

Of 392 total patients, 95 had restorative and 297 had non-restorative surgery. Patients undergoing restorative surgery, compared to non-restorative surgery, were significantly younger (P<0.01), had lower incidences of steroid usage (P<0.001) and higher rates of readmission (P = 0.02). There were no differences in post-operative complications between the groups in both unadjusted analyses and covariate-adjusted regression analysis (P > 0.05).

CONCLUSION

In carefully selected older patients with ulcerative colitis, restorative surgery is associated with increased readmission, but otherwise similar rates of morbidity or mortality compared to non-restorative surgery. Data regarding postoperative functional outcome and quality of life are also needed to help select the most appropriate curative option for older adults.

Ileal pouch-anal anastomosis in the elderly: A systematic review and meta-analysis

AIM

Despite good overall outcomes in most patients undergoing ileal pouch-anal anastomosis (IPAA), there is still hesitation about performing an IPAA in older patients due to the comorbidity burden and concern about incontinence. The aim of this work was to identify short- and long-term outcomes in older patinets undergoing IPAA to determine the perioperative safety and long-term functional success of IPAA in older patients.

METHOD

A literature search was performed for all publications on IPAA in adults aged ≥50 years that reported short- and long-term outcomes. Data extraction included demographics, 30-day outcomes, long-term functional outcomes and pouch failure. Data were further separated by age group (50-65 and ≥65 years). Outcomes were compared between age groups. Study quality and risk of bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

Of 1053 publications reviewed, 13 full papers were included in the analysis. The overall 30-day morbidity and mortality rates were 47.3% and 1.3%, respectively. Thirty-day postoperative rates of small bowel obstruction and pelvic sepsis were 7.6% and 9.9%, respectively. After a median follow-up time of 62 months, rates of pouchitis, incontinence and pouch failure were 13.9%, 17.5% and 7.5%, respectively. There was no statically significant difference in rates of short- or long-term functional outcomes based on age 50-65 versus ≥65 years.

CONCLUSION

Increasing age did not increase the rate of short- or long-term outcomes, including pouch failure. These data suggest that the decision for IPAA construction should not be based on age alone.

Management of elderly ulcerative colitis in Japan

Japan has the largest aging society, where many elderly people have intractable diseases including ulcerative colitis (UC). Along with the increasing total number of UC patients, the number of elderly UC patients has also been increasing and will continue to do so in the future. Although the clinical features and natural history of UC in the elderly have many similarities with UC in the non-elderly population, age-specific concerns including comorbidities, immunological dysfunction, and polypharmacy make the diagnosis and management of elderly UC challenging compared to UC in non-elderly patients. Based on increasing data related to elderly UC patients from Japan, as well as other countries, we reviewed the epidemiology, clinical course, differential diagnosis, management of comorbidities, surveillance, medical therapy, and surgery of UC in the elderly.

Outcomes and Management of the Ileal Pouch-Anal Anastomosis in the Elderly

PURPOSE OF REVIEW

Ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment for patients undergoing colectomy to maintain intestinal continuity. Earlier studies have suggested that outcomes are worse in elderly patients who underwent IPAA. However, more recent reports have shown that IPAA outcomes in the elderly are comparable to younger patients. We review the recent medical literature regarding outcomes and treatments for common complications in elderly IPAA patients.

RECENT FINDINGS

Compared to younger patients, IPAA in the elderly is not associated with increased major surgical complications, but is associated with increased length of stay and re-admission rate for dehydration in older patients. Rates of fecal incontinence after IPAA were similar between younger and older patients. Sacral nerve stimulation has shown early promise as a possible treatment for fecal incontinence after IPAA, but more research is needed. Pouchitis is a common complication, and antibiotics remain first-line treatment options. Other treatment options include mesalamines, steroids, immunomodulators, and biologics. The efficacy of newer biologics such as vedolizumab and ustekinumab has been reported, but more data is needed. IPAA is safe in the elderly with high self-reported patient satisfaction. However, the elderly IPAA patient warrants special consideration regarding outcomes and management.

The Impact of Age at Time of Ileal Pouch Anal Anastomosis on Short and Long-Term Outcomes in Adults

BACKGROUND

There is limited knowledge on ileal pouch anal anastomosis (IPAA) function when performed on patients older than age 50 years. The aim of this study was to determine if surgery on those older than age 50 years impacts short-term complications or long-term function.

METHODS

A retrospective review of all patients undergoing IPAA for chronic ulcerative colitis at a single tertiary referral center between 2002 and 2013 was conducted. Short-term postoperative complications and long-term function and quality of life were analyzed according to age at pouch formation (age >50 vs age ≤50 years).

RESULTS

A total of 911 patients who underwent IPAA (542 male) were included, with 178 patients (20%) age >50 years and 733 (80%) ≤50 years. Patients >50 years had higher American Society of Anesthesiology score (ASA) scores and increased rates of obesity and dysplasia or cancer at the time of colectomy, and were less often on steroids (all P < 0.01). Over a median follow-up of 5 years, older patients reported increased daytime incontinence (60% vs 37%, P < 0.01) and pad usage (34% vs 11%, P < 0.01) at up to 1.5 years post-IPAA, after which time the groups became similar. Other functional outcomes, including pouch failure and quality of life, were similar between the 2 groups across the follow-up periods.

CONCLUSION

Performing an IPAA on carefully selected patients older than age 50 years has minor, transient differences in pouch function compared with patients younger than age 50 years. Assuming appropriate patient selection, IPAA should continue to be offered to older patients without increased risk of compromised function or of pouch failure.

Restorative Proctocolectomy in Elderly IBD Patients: A Multicentre Comparative Study on Safety and Efficacy

BACKGROUND AND AIMS

Restorative proctocolectomy in elderly inflammatory bowel disease [ IBD] patients is controversial and limited data are available on the outcomes of surgery. The aim of this study was to evaluate the safety, efficacy, and long-term results of ileal-pouch-anal anastomosis in elderly patients, in a multicentre survey from European referral centres.

METHODS

The International Pouch Database [IPD] combined 101 variables. Patients aged ≥ 65 years were matched on the basis of open versus laparoscopic surgery with a control group of consecutive younger unselected patients with a ratio of 1:2. Statistical analysis was performed using two-tailed t test, chi square and Fisher's exact tests, Kaplan-Meier function, and log-rank tests where appropriate.

RESULTS

In the IPD, 77 patients aged ≥ 65 years [Group A] and 154 control patients [Group B] were identified. Elderly patients had more comorbidities [p = 0.0001], longer disease duration [p = 0.001], less extensive disease [p = 0.006], more previous abdominal operations [p = 0.0006], surgery for cancer or dysplasia more frequently [p = 0.0001], fewer single-stage procedures [p = 0.03], more diversions after ileal pouch-anal anastomosis [IPAA] [p = 0.05], and a higher laparoscopic conversion rate [p = 0.04]. Postoperative complications and pouch failure were similar between the groups, but Group A had more Clavien-Dindo IV-V complications [p = 0.04], and longer length of stay [p = 0.007]. Laparoscopy was associated with a shorter duration of surgery [p = 0.0001], and length of stay [p = 0.0001], and the same complication rate as open surgery.

CONCLUSIONS

Restorative proctocolectomy can be performed in selected elderly patients, but there is a higher risk of postoperative complications and longer length of stay in this group. Laparoscopy is associated with shorter operating time and length of stay.

European Crohn's and Colitis Organisation Topical Review on IBD in the Elderly

This ECCO topical review of the European Crohn's and Colitis Organisation [ECCO] focuses on the epidemiology, pathophysiology, diagnosis, management and outcome of the two most common forms of inflammatory bowel disease, Crohn's disease and ulcerative colitis, in elderly patients. The objective was to reach expert consensus to provide evidence-based guidance for clinical practice.

Functional outcomes following ileal pouch-anal anastomosis (IPAA) in older patients: a systematic review

AIM

Ileal pouch-anal anastomosis (IPAA) is performed in ulcerative colitis or familial adenomatous polyposis with a view to restoration of GI continuity and prevention of permanent faecal diversion. Debate exists as to its safety in older patients. This review aims to assess functional outcomes and safety of restorative proctocolectomy (RPC) in older compared to younger patients.

METHODS

Literature search was performed for age-stratified studies which assessed functional outcomes of IPAA. Twelve papers were included overall. Patients were categorized into 'older' and 'younger' groups. Analysis was split into three separate parts: 1. Age cut-off of 50 ± 5 years (with sensitivity analysis); 2. Age cut-off of 65 ± years; 3. Long-term outcomes (>10 years).

RESULTS

With an age cut-off of 50 years (4327 versus 513 patients), complication rates were comparable with the exception of an increased rate of small-bowel obstruction in the younger patients (p = 0.034). At 1 year, 24-h stool frequency was significantly higher in the older patient group (p < 0.0001). Daytime (p < 0.0001) and night-time (p < 0.0001) incontinence rates were also significantly higher in older patients. Overall, function deteriorated with time across all ages; however, after 10 years, there was no significant difference in incontinence rates between age groups. Dehydration and electrolyte loss was a significant problem in patients over 65 (p < 0.0001). Despite differences in postoperative function, quality of life was comparable between groups; however, only a few studies reported quality of life data.

CONCLUSION

IPAA is safe in older patients, although treating clinicians should bear in mind the increased risk of dehydration. Postoperative function is worse in older patients, but seems to level out with time and does not appear to significantly impact on overall quality of life and patient satisfaction. Assessment for suitability for RPC should not be based on chronological age in isolation. It is imperative that the correct support is given to older patients with worsened postoperative function in order to maintain patient satisfaction and adequate quality of life.

Proctocolectomy for colorectal cancer--is the ileal pouch anal anastomosis a safe alternative to permanent ileostomy?

PURPOSE

Ileal pouch anal anastomosis (IPAA) is the procedure of choice in patients requiring surgery for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). There are few data on reconstruction with the IPAA in patients with colorectal cancer (CRC). This study assessed the outcomes of the IPAA compared to proctocolectomy and permanent ileostomy (PI) on these patients.

METHODS

Between 1983 and 2013, over 2800 patients with CRC have been treated at the Mount Sinai Hospital (MSH). Demographic, surgical, pathological, and outcome data for all patients have been maintained in a database-73 patients were treated for CRC with proctocolectomy: 39 patients with IPAA and 34 patients with PI. Clinical features, pathologic findings, and survival outcomes were compared between these groups.

RESULTS

Each group was similar with respect to gender, stage, and histologic grade. Patients undergoing IPAA were significantly younger. The diagnosis leading to proctocolectomy was more commonly UC or FAP in patients treated with IPAA (39/39 vs. 23/34, p = 0.001). Rectal cancer subgroups were similar in age, sex, TNM stage, T-stage, height of tumor, and histologic grade. There was no significant difference in overall or disease free survival between groups for colon or rectal primaries. Analysis using the Cochran-Armitage trend test suggests that utilization of IPAA has increased over time (p = 0.002).

CONCLUSIONS

The IPAA is a viable and safe option to select for patients who would otherwise require PI. Increased experience and improved outcomes following IPAA has led to its more liberal use in selected patients.

Comparable pouch retention rate between pediatric and adult patients after restorative proctocolectomy and ileal pouches

BACKGROUND & AIMS

We compared long-term outcomes between adult and pediatric patients with inflammatory bowel disease (IBD) who underwent restorative proctocolectomy with ileal pouch-anal anastomosis.

METHODS

We performed a retrospective study that analyzed data from consecutive patients with ileal pouches who presented to the subspecialty Pouch Center at the Cleveland Clinic from 2002-2011. Pouch outcomes of 104 pediatric patients (having pouch surgery at age <18 years; 53 male) were compared with those of 1135 adults (having pouch surgery at an age 18 years or older; 632 male).

RESULTS

Pediatric patients had a shorter duration from time of IBD diagnosis to colectomy than adult patients. Fewer pediatric than adult patients had a history of smoking, concomitant extraintestinal manifestations, or dysplasia as the indication for colectomy. However, pediatric patients had higher rates of pouch procedure-related complications, postoperative pouch-associated hospitalization, and postoperative use of anti-tumor necrosis factor (TNF) agents. In multivariate analysis, risk factors for pouch failure included preoperative use of anti-TNF agents (hazard ratio [HR], 1.81; 95% confidence interval [CI], 1.05-3.13; P = .032), postoperative use of anti-TNF agents (HR, 2.07; 95% CI, 1.31-3.27; P = .002), Crohn's disease of the pouch (HR, 2.21; 95% CI, 1.28-3.82; P = .005), pouch procedure-related complications (HR, 2.68; 95% CI, 1.55-4.64; P < .001), and postoperative pouch-associated hospitalization (HR, 25.20; 95% CI, 14.44-43.97; P < .001). Being a pediatric patient was not significantly associated with pouch failure in univariate or multivariate analyses (HR, 0.6; 95% CI, 0.32-1.16; P = .13).

CONCLUSIONS

On the basis of an analysis of patients with IBD who underwent restorative proctocolectomy and presented at a subspecialized Pouch Center, patients who had the surgery at a pediatric age tend to have a higher incidence of postoperative pouch complications than adults. However, long-term rates of pouch retention were comparable.

Ileal pouch-anal anastomosis: Points of controversy

Restorative proctocolectomy with ileal pouch-anal anastomosis has become the most commonly used procedure for elective treatment of patients with ulcerative colitis and familial adenomatous polyposis. Since its original description, the procedure has been modified in order to obtain optimal functional results with low morbidity and mortality, and yet provide a cure for the disease. In this review of the literature of restorative proctocolectomy with ileal pouch-anal anastomosis, we discuss these technical modifications, limiting our discussion to the current points of controversy. The current "hot topics" for debate are: indications for ileal pouch-anal or ileo-rectal anastomosis, indications for pouch surgery in the elderly, indeterminate colitis and Crohn's disease, the place of the laparoscopic approach, transanal mucosectomy with hand-sewn anastomosis vs. the double-stapled technique, the use of diverting ileostomy and the issue of the best route for delivery of pregnant women. Longer follow-up of patients and increased knowledge and experience with pouch surgery, coupled with ongoing prospective evaluation of the procedure are required to settle these issues.

Surgical outcomes in the elderly with inflammatory bowel disease are similar to those in the younger population

BACKGROUND

Inflammatory bowel disease (IBD) has a bimodal distribution with approximately 15 % of patients manifesting after age 65. Previous reports suggest an increased risk of surgical complications in the elderly.

AIM

To compare surgical outcomes in elderly IBD patients (≥ 65 years at the time of surgery) to matched younger IBD cohorts.

METHODS

This was a retrospective cohort study at a single academic center of patients who underwent surgery for IBD. Forty-two elderly patients (≥ 65 years) were matched at least 1:1 (median 1:5) to patients in each of three control groups [18-35 years (n = 71); 36-49 years (n = 62); 50-64 years (n = 58)] according to gender, disease type/location, and type of surgery. Postoperative complications were compared. Patient characteristics were used in multivariate risk models. Analysis was performed using ordinary logistic regression.

RESULTS

Twenty ileal or ileocolonic resections, 12 partial or total colectomies, four stricturoplasties, and six laparoscopic partial or total colectomies were performed in the elderly group. The post-operative complication rate was not statistically different between the elderly and younger cohorts (38 % vs. 39 % vs. 40 % vs. 48 % in the 18-35, 36-49, 50-64, and ≥ 65 years groups, respectively, p = 0.26). The only significant risk factors for complication were Charlson comorbidity index (p = 0.0002), preoperative hemoglobin (p = 0.0065), total parenteral nutrition use (p = 0.024), and failed medical therapy (as the indication for surgery) (p = <0.0001).

CONCLUSIONS

The surgical complication rate among elderly and younger IBD patients was similar. Advanced age by itself should not be considered a risk factor for adverse operative outcome.

Medical and surgical therapy of inflammatory bowel disease in the elderly - prospects and complications

Population ageing is a global phenomenon. People aged 65 years and older comprise approximately 16% of the population of Europe. The medical management of elderly patients with inflammatory bowel disease (IBD) is challenging with respect to diagnosis, pharmaceutical and surgical treatment, and complications. IBD has a late onset in 10%-15% of patients, with the first flare occurring at 60 to 70 years of age; others suffer from the disease for several decades. Even though the natural course of the disease in geriatric populations and the diagnostic options may not differ much from those in younger patients, distinct problems exist in the choice of medical therapy. Recommended clinical practise has been rapidly evolving towards an intensified initial treatment in IBD. However, in patients older than 65 years, a gentler approach should be used, and a combination of immunosuppressive agents should be avoided because of increased risk of infectious and neoplastic complications. Furthermore, elderly patients with severe IBD show prolonged, complicated post-operative clinical courses with worse hospital outcomes, so early surgical intervention for elderly patients is recommended. This article provides an overview of elderly IBD patient care, including medical and surgical therapeutic considerations and emphasises the necessity of close collaborations between gastroenterologists and surgeons.

Ileal pouch-anal anastomosis in elderly patients: is there a difference in morbidity compared with younger patients?

AIM

The aim of this study was to review the recent results of ileal pouch-anal anastomosis (IPAA) in elderly patients compared with younger patients.

METHOD

Retrospective evaluation was carried out based on a prospective Institutional Review Board approved database of patients who underwent IPAA from 2001 to 2008. Patients aged ≥ 65 years were matched with a group of patients aged < 65 years by gender, date of procedure, diagnosis and type of procedure performed. Preoperative and intra-operative data and early postoperative complications were obtained.

RESULTS

Thirty-three patients (22 women), 32 with mucosal ulcerative colitis, were included in each group. The elderly group had a mean age of 68.7 years, body mass index of 27 kg/m², duration of disease of 17.4 years, high American Society of Anesthesiologists (ASA) score and high incidence of comorbid conditions (87.9% had one or more). Dysplasia and carcinoma were the indication for the surgery in more than 50% of patients, followed by refractory disease (24.4%). The matched younger group had a mean age of 36.9 years, body mass index of 25.4 kg/m², shorter duration of disease (8.1 years; P = 0.001), lower ASA score (P = 0.0001) and lower comorbidity (42.4%; P = 0.0002). Operative data were similar for both groups. The elderly group had a higher rate of rehospitalization for dehydration (P = 0.02). Other medical complications (30 vs 27%) and surgical postoperative complications (33 vs 24%) were similar for both groups. The long-term function and complications were comparable for the groups.

CONCLUSION

Elderly patients who underwent IPAA had more comorbid conditions than younger patients. Except for rehospitalization for dehydration, medical and surgical postoperative complications were not different in the two groups.

Surgery for ulcerative colitis

Ulcerative colitis is an inflammatory condition of unknown aetiology affecting all or part of the rectum and colon. The mainstay of treatment is medical but there are specific indications for surgical intervention. This article reviews the evolution of surgical management and in particular compares outcome from proctocolectomy and pouch surgery. A number of factors determining choice of procedure are examined, including elective or emergency presentation, patient selection, technical issues, morbidity and quality of life. Emphasis is made regarding a full explanation of these factors so that the patient is fully involved in the final decision regarding choice of procedure.

Ileal pouch surgery for ulcerative colitis

Ulcerative colitis (UC) is a relapsing and remitting disease characterised by chronic mucosal and submucosal inflammation of the colon and rectum. Treatment may vary depending upon the extent and severity of inflammation. Broadly speaking medical treatments aim to induce and then maintain remission. Surgery is indicated for inflammatory disease that is refractory to medical treatment or in cases of neoplastic transformation. Approximately 25% of patients with UC ultimately require colectomy. Ileal pouch-anal anastomosis (IPAA) has become the standard of care for patients with ulcerative colitis who ultimately require colectomy. This review will examine indications for IPAA, patient selection, technical aspects of surgery, management of complications and long term outcome following this procedure.

Revolution and evolution: 30 years of ileoanal pouch surgery

Ileal pouch-anal anastomosis (IPAA) has become the standard of care for the 25% of patients with ulcerative colitis who ultimately require colectomy. IPAA is favored by patients because it avoids the necessity for a long-term stoma. This review examines how 3 decades of experience with IPAA has molded current practice, highlighting 5- and 10-year follow-up of large series to determine durability and functional performance, in addition to causes of failure and the management of complications.

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.

Prospective, age-related analysis of surgical results, functional outcome, and quality of life after ileal pouch-anal anastomosis

OBJECTIVE To evaluate how age affects functional outcome and quality of life after ileal pouch anal anastomosis (IPAA). SUMMARY BACKGROUND DATA Because of the limited number of older patients undergoing IPAA, it has been difficult to assess functional outcome and quality of life stratified by age. METHODS IPAA was performed in 1895 patients. Patients were stratified by age into <45 (n = 1410), 46-55 (n = 289), 56-65 (n = 154), and more than 65 years (n = 42). Outcome was assessed prospectively. Results are presented at 1, 3, 5, and 10 years after surgery.RESULTS Patients were followed for 4.6 +/- 3.7 years (maximum, 17 years). Pouch failure occurred in 4.1% (pouch excision or permanent diversion). Incontinence and night time seepage were more common in older patients. There were minor differences in the quality of life, health, energy and happiness between age groups, with a slight benefit for those under 45 years. Fourteen percent or fewer patients experienced social, sexual or work restrictions. Overall, 96% of patients were happy to have undergone their surgery, and 98% recommended it to others. Although the respective figures were 89% and 96% in the over-65 age group, the difference was not significant. CONCLUSIONS These data provide a unique assessment of outcome after IPAA at multiple time points. Although functional outcome after IPAA is not as good in older patients, appropriate case selection confers acceptable function and quality of life to patients of all ages.

Current controversies in pouch surgery

Restorative proctocolectomy with ileal pouch anal anastomosis has become the most commonly used procedure for elective treatment of patients with mucosal ulcerative colitis and familial adenomatous polyposis. Since its original description, the procedure has been modified in an attempt to obtain optimal functional results with low morbidity and mortality, and yet provide a cure for the disease. These modifications of the technique are discussed in this review, limited to the current points of controversy. We reviewed the current literature describing restorative proctocolectomy with ileal pouch anal anastomosis. The current "hot topics" for debate are transanal mucosectomy with hand-sewn anastomosis versus the double-stapled technique, the use of diverting ileostomy, indeterminate colitis, the role of laparoscopy, and indications for pouch surgery in the elderly. Longer follow-up of patients and increased knowledge and experience with pouch surgery, coupled with active prospective evaluation of the procedure are required to settle these issues. Patients must be fully informed to understand inherent risks of each choice.

Surgical management of a long efferent loop after J-pouch ileoanal reconstruction

PURPOSE

To demonstrate a simple and effective repair of a poorly constructed ileal J-pouch with an extensive long efferent limb.

METHOD

A retrospective case review was performed.

RESULTS

The surgical procedure described preserves additional ileum and enlarges the ileal reservoir. The procedure succeeded in resolving the patient's complaints of partial obstruction, weight loss, and increased stool frequency. At five-month follow-up, the patient was doing well with three to six stools daily. Evaluation of the new ileal J-pouch showed no signs of inflammation, and the pouch size measured more than 20 cm compared with 12 cm preoperatively.

CONCLUSIONS

Repair of a long efferent limb by this simple stapling technique is feasible, simple, and effective, with an excellent clinical result. It preserves valuable small intestine and enlarges the capacity of the reservoir, leading to better functional outcome.

Outcome of pouch-related complications after ileal pouch-anal anastomosis

BACKGROUND

Creation of a small intestinal reservoir after ileal pouch-anal anastomosis (IPAA) results in an improved quality of life because of significantly diminished stool frequency. However, a number of complications associated with the pouch may jeopardize these sphincter-sparing procedures and occasionally result in permanent ileostomy. This study was conducted to assess the incidence, risk factors, clinical characteristics, management strategies, and outcome of pouch-related complications after IPAA.

METHODS

Data on all patients undergoing IPAA with a J pouch between 1983 and Spring 1997 were prospectively gathered. Patients with pouch-specific complications were identified, and both inpatient and outpatient records analyzed in detail. When necessary, telephone contact was made to update functional data. Other parameters evaluated included age, gender, diagnosis, medication history, diagnostic modalities, laboratory values, time course, management strategies, reoperative procedures, and final results.

RESULTS

Some 510 IPAA procedures were performed between 1983 and Spring 1997; 87% of patients had inflammatory bowel disease. Operative mortality was 0%. In the entire series, 27 (5.3%) had complications related to the J pouch. Of those, 22 (81%) had ulcerative colitis and were on a mean dose of 32 mg/day of prednisone. Computed tomography scan made the diagnosis in 18 (67%) and the mean white blood cell count on admission was 14,400. In 11 (41%), the complications occurred after IPAA whereas in the other 16 (59%) it occurred after ileostomy closure. In 5 (19%), the complication resolved with intravenous antibiotics and percutaneous drainage, and 22 (81%) required reoperation. Proximal (11, or 41%) and distal (8, or 30%) pouch leaks or cuff abscesses were the most common complication and accounted for 19 (70%) of the complications observed. In this series, 3 patients (11%) had complications severe enough to warrant J pouch excision, and 1 patient had a permanent ileostomy without excision. Overall pouch excision/ failure in this series was 0.78%.

CONCLUSION

Complications involving the J pouch are a seemingly unavoidable part of sphincter-sparing surgery for colonic mucosal diseases. However, if therapy is timely, aggressive, and judicious for these complex patients, pouch loss should be uncommon and long-term results acceptable.