Quality of life after total colectomy with ileorectal anastomosis or proctocolectomy and ileal pouch-anal anastomosis for familial adenomatous polyposis

Marital status after colorectal surgery in familial adenomatous polyposis: a nationwide multicenter study in Japan

BACKGROUND

Patients with familial adenomatous polyposis (FAP) experience psychological and social challenges concerning future events such as marriage and childbirth alongside the medical risks of colorectal cancer (CRC) and FAP-related disease. We retrospectively investigated the rate of marriage and childbirth postoperatively in Japanese patients with FAP.

METHODS

We included 161 patients who had colorectal surgery and reported marital status from a national survey of 35 Japanese institutions. Participants were classified according to marital status: married before colectomy (80 patients), married after colectomy (13 patients), and unmarried (68 patients).

RESULTS

The marriage rate for all 161 patients (57.8%, standardized ratio 0.95, 95% confidence interval [CI] 0.76-1.14) was comparable to that in the general Japanese population (57.1%). The marriage rate among the 81 patients who were unmarried before colectomy was low (16.0%); however, the standardized marital ratio (0.75, 95% CI 0.34-1.15) was not significantly lower than that of the general population. In multivariable logistic regression, younger age (born after 1980, odds ratio [OR] 0.12, p < 0.001) and genetic testing (OR 4.06, p = 0.001) were associated with postoperative marriage. Seventy-one percent of patients with FAP who married after colectomy became pregnant and achieved delivery.

CONCLUSIONS

The marriage rate of patients with FAP was comparable to that of the general population whereas the rate after colectomy was low among patients with FAP. However, in patients with FAP, colorectal surgery itself may not lead to negative consequences in terms of fecundity.

Quality of life after prophylactic surgery for colorectal adenomatous polyposis

PURPOSE

Colorectal adenomatous polyposis is characterized by the onset of tens to thousands of adenomas in the colorectal epithelium and, if not treated, leads to a lifetime increased risk of developing colorectal cancer compared to the general population. Thus, prophylactic surgery is recommended. This study aims to investigate the quality of life of colorectal adenomatous polyposis patients following prophylactic surgery and indirectly compares these findings with those of healthy adults of the normative sample.

METHODS

All patients who underwent prophylactic surgery for polyposis and were in follow-up at the hereditary digestive tract tumors outpatient department of our institute were eligible for the study. The Short Form-36 questionnaire and 21 ad hoc items were used at the time of clinical evaluation.

RESULTS

A total of 102 patients were enrolled. For the SF-36 domains, mean values ranged from 64.18 for vitality to 88.49 for physical functioning, with the highest variability for role-physical limitations; the minimum value of functioning was reached for role-physical limitations, role-emotional limitations, and social functioning. The maximum value of functioning was reached for role-emotional limitations (73.96%) and role-physical limitations (60.42%). In total, 48.96% and 90.63% of patients reported no fecal or urinary incontinence episodes, respectively; 69.79% of patients did not have problems in work/school resumption or the personal sexual sphere.

CONCLUSION

Quality of life following prophylactic surgery for these patients seems to be good when indirectly compared to HP-normative samples'. Young adult patients appear to quickly manage and adapt to changes in bowel functioning. A minority of patients may experience social and sexual issues.

Management of familial adenomatous polyposis and MUTYH-associated polyposis; new insights

Familial adenomatous polyposis (FAP) and MUTYH-associated polyposis (MAP) are rare inherited polyposis syndromes with a high colorectal cancer (CRC) risk. Therefore, frequent endoscopic surveillance including polypectomy of relevant premalignant lesions from a young age is warranted in patients. In FAP and less often in MAP, prophylactic colectomy is indicated followed by lifelong endoscopic surveillance of the retained rectum after (sub)total colectomy and ileal pouch after proctocolectomy to prevent CRC. No consensus is reached on the right type and timing of colectomy. As patients with FAP and MAP nowadays have an almost normal life-expectancy due to adequate treatment of colorectal polyposis, challenges in the management of FAP and MAP have shifted towards the treatment of duodenal and gastric adenomas as well as desmoid treatment in FAP. Whereas up until recently upper gastrointestinal surveillance was mostly diagnostic and patients were referred for surgery once duodenal or gastric polyposis was advanced, nowadays endoscopic treatment of premalignant lesions is widely performed. Aiming to reduce polyp burden in the colorectum as well as in the upper gastrointestinal tract, several chemopreventive agents are currently being studied.

Intensive surveillance endoscopy for multiple gastrointestinal tumors in a patient with constitutional mismatch repair deficiency: case report

BACKGROUND

Constitutional mismatch repair deficiency (CMMRD) is an extremely rare autosomal recessive hereditary disease characterized by the absence of mismatch repair gene activity from birth, which results in brain tumors, colonic polyposis, gastrointestinal cancers, and lymphomas later in life. An aggressive approach, including colectomy or proctocolectomy, is recommended for the treatment of colorectal cancer. Additionally, partial colectomy with subsequent endoscopic surveillance may be an alternative strategy due to poor patient's condition, although there is no evidence of surveillance endoscopy after partial colectomy for CMMRD.

CASE PRESENTATION

A 13-year-old male patient with a history of T-lymphoblastic lymphoma underwent total gastrointestinal endoscopy, which revealed rectal cancer, colorectal polyposis, and duodenal adenoma. Differential diagnosis included constitutional mismatch repair deficiency according to its scoring system and microsatellite instability, and subsequent germline mutation testing for mismatch repair genes confirmed the diagnosis of constitutional mismatch repair deficiency based on a homozygous mutation in mutS homolog 6 (MSH6). The patient and his family refused colectomy due to the high risk of malignancies other than colorectal cancer, which could require radical surgery. Therefore, the patient underwent low anterior resection of the rectosigmoid colon for rectal cancer and intensive surveillance endoscopy for the remaining colon polyposis. During the 3-year period after initial surgery, 130 polyps were removed and the number of polyps gradually decreased during 6-months interval surveillance endoscopies, although only one polyp was diagnosed as invasive adenocarcinoma (pT1).

CONCLUSIONS

Our experience of short surveillance endoscopy illustrates that this strategy might be one of options according to patient's condition.

Trends in Diverting Loop Ileostomy vs Total Abdominal Colectomy as Surgical Management for Clostridium difficile Colitis

Importance

Diverting loop ileostomy and colonic lavage has generated much interest since it was first reported as a potential alternative to total abdominal colectomy for treating Clostridium difficile colitis in 2011. To our knowledge, few studies have validated the benefit reported in the initial description, and the association of this new approach with practice patterns has not been described.

Objective

To examine the national adoption pattern and outcomes of diverting loop ileostomy vs total abdominal colectomy as treatment for fulminant C difficile colitis.

Design, Setting, and Participants

This retrospective cohort study used data from hospitals participating in the National Inpatient Sample database across the United States from January 2011 to September 2015 and included 3021 adult patients who underwent surgery for C difficile colitis during the study period, comprising 2408 subtotal colectomies and 613 loop ileostomies. The data were analyzed between November 2018 and April 2019.

Exposures

Loop ileostomy as surgery of choice.

Main Outcomes and Measures

In-hospital mortality.

Results

Of 2408 participants, 1416 (58.8%) were women, 1781 (78.4%) were white, and 627 (21.6%) were individuals of color and the mean (SD) age was 68.2 (14.8) years. During the overall study period, 613 patients (20.28%) underwent diverting loop ileostomy without total abdominal colectomy. The annual proportion of patients undergoing only diversion increased from 11.16% in 2011 to 25.30% in 2015. Significantly more loop ileostomies were performed within the first day of hospitalization, in contrast to subtotal colectomies (23.31% vs 12.21%; P < .01). There was no significant difference in in-hospital mortality rates between the 2 groups (25.98% vs 31.18%; P = .28).

Conclusions and Relevance

This study demonstrates the adoption of diverting loop ileostomy to treat C difficile colitis across the United States. While fulminant C difficile colitis remains a condition with high mortality rates, no significant difference in this outcome was observed between loop ileostomy and total abdominal colectomy. Loop ileostomy may represent a viable surgical alternative to total abdominal colectomy, although the grounds for selection of treatment need to be clarified.

Optimizing the timing of colorectal surgery in patients with familial adenomatous polyposis in clinical practice

Background: Familial adenomatous polyposis (FAP) is characterized by the development of hundreds of colorectal adenomas in the second decade of life, and prophylactic colectomy is usually performed around age of 20. A common question is the appropriate timing of surgery and which endoscopic findings indicate surgery. Methods: All FAP patients known at Leiden University Medical Centre from 1985 onwards were included. The patients were then subdivided into those diagnosed before or after 2000. Patient information included age at diagnosis, colonic phenotype, age at surgery, pathological findings and the outcome of follow-up colonoscopies in whom surgery was postponed. Results: The 72 FAP patients identified consisted of 33 patients diagnosed before (group A) and 39 after (group B) 2000. The median age at diagnosis for patients with classical FAP was 18 in groups A and B. All patients diagnosed before 2000 underwent colorectal surgery versus 68% of those diagnosed >2000. The median age at surgery for classical FAP patients was 19 and 24 years in groups A and B, respectively. In patients with intact colon, the number of adenomas gradually increased over many years. Although most adenomas remained <5 mm, the proportion of 5-15 mm adenomas slowly increased. Only one patient developed a high-grade adenoma. None of the patients developed CRC. Conclusions: Surgery today in FAP is performed less often and at a more advanced age. Our experience also suggests that surgery can be safely postponed in selected patients. The most important endoscopic indication for surgery is substantial number of large adenomas of >5-10 mm.

Life After Surgery: Surgeon Assessments of Quality of Life Among Patients With Familial Adenomatous Polyposis

BACKGROUND

Without prophylactic surgery, patients with familial adenomatous polyposis are at high risk for colorectal cancer development. Various surgical options for prophylaxis are available. Patient decision-making for preventative treatments is often influenced by the preferences of healthcare providers.

OBJECTIVE

We determined surgeon preferences for the surgical options available to patients with familial adenomatous polyposis.

DESIGN

We obtained preference estimates for postoperative health states from colorectal surgeons who had treated ≥10 patients with familial adenomatous polyposis.

SETTINGS

Assessments were made at an annual meeting of the American Society of Colon and Rectal Surgeons.

MAIN OUTCOME MEASURES

Utilities were measured through the time trade-off method. We determined utilities for 3 procedures used for prophylaxis, including total proctocolectomy with permanent ileostomy, colectomy with ileorectal anastomosis, and total proctocolectomy with IPAA. We also assessed utilities for 2 short-term health states: 90 days with a temporary ileostomy and 2 years with a poorly functioning ileoanal pouch.

RESULTS

Twenty-seven surgeons who had cared for >1700 patients with familial adenomatous polyposis participated in this study. The highest utility scores were provided for colectomy with ileorectal anastomosis (0.98). Lower utility scores were provided for total proctocolectomy with permanent ileostomy (0.87) and IPAA (0.89). The number of patients with familial adenomatous polyposis who were treated by participating surgeons did not influence these estimates; however, more-experienced surgeons gave lower utility scores for a poorly functioning ileoanal pouch than less-experienced surgeons (0.15, 0.50, and 0.25 for high-, medium-, and low-volume surgeons; p = 0.02).

LIMITATIONS

This study was limited by the sample size.

CONCLUSIONS

For patients with familial adenomatous polyposis and relative rectal sparing, surgeon preferences are greatest for colectomy with ileorectal anastomosis. Utility estimates provided by this study are important for understanding surgical decision-making and suggest a role for ileorectal anastomosis in appropriately selected patients. See Video Abstract at http://links.lww.com/DCR/A656.

Quality-of-life implications of risk-reducing cancer surgery

Background

Modern advances in genetic sequencing techniques have allowed for increased availability of genetic testing for hereditary cancer syndromes. Consequently, more people are being identified as mutation carriers and becoming aware of their increased risk of malignancy. Testing is commonplace for many inheritable cancer syndromes, and with that comes the knowledge of being a gene carrier for some patients. With increased risk of malignancy, many guidelines recommend that gene carriers partake in risk reduction strategies, including risk-reducing surgery for some syndromes. This review explores the quality-of-life consequences of genetic testing and risk-reducing surgery.

Methods

A narrative review of PubMed/MEDLINE was performed, focusing on the health-related quality-of-life implications of surgery for hereditary breast and ovarian cancer, familial adenomatous polyposis and hereditary diffuse gastric cancer.

Results

Risk-reducing surgery almost uniformly decreases cancer anxiety and affects patients' quality of life.

Conclusion

Although the overwhelming quality-of-life implications of surgery are neutral to positive, risk-reducing surgery is irreversible and can be associated with short- and long-term side-effects.

Chemoprevention of hereditary colon cancers: time for new strategies

Colorectal cancer (CRC) is potentially preventable. Chemoprevention, a focus of research for the past three decades, aims to prevent or delay the onset of cancer through the regression or prevention of colonic adenomas. Ideal pharmacological agents for chemoprevention should be cheap and nontoxic. Although data indicate that aspirin can reduce the risk of CRC in the general population, the highest return from chemopreventive strategies would be expected in patients with the highest risk of developing the disease, particularly those with a defined hereditary predisposition. Despite compelling data showing that a large number of chemopreventive agents show promise in preclinical CRC models, clinical studies have yielded conflicting results. This Review provides a historical and methodological perspective of chemoprevention in familial adenomatous polyposis and Lynch syndrome, and summarizes the current status of CRC chemoprevention in humans. Our goal is to critically focus on important issues of trial design, with particular attention on the choice of appropriate trial end points, how such end points should be measured, and which patients are the ideal candidates to be included in a chemopreventive trial.

Comparison of proctocolectomy and ileal pouch-anal anastomosis to colectomy and ileorectal anastomosis in familial adenomatous polyposis

Prophylactic surgical options for familial adenomatous polyposis (FAP) are either colectomy and ileorectal anastomosis (IRA) or proctocolectomy and ileal pouch-anal anastomosis (IPAA). The aim of this study was to analyse the short-term and long-term outcomes of these two operative techniques. All patients with FAP in Finland have been prospectively recorded in a database since 1963 were retrospectively reviewed in this analysis. Altogether 140 (61%) colectomies with IRA and 88 (39%) proctocolectomies with IPAA have been performed. Complications occurred in 28 (21%) patients after IRA and in 26 (30%) patients after IPAA. There were 15 (11%) severe complications for IRA and 5 (6%) for IPAA. Twenty-one (15%) patients of the IRA group ended up in conventional ileostomy whereas 3 (3.4%) patients of the IPAA group had their ileal reservoir converted to an ileostomy (p = 0.01). Cumulative survival for IRA was lower than for the IPAA (p = 0.03), but if accounting only for operations made after the IPAA era had commenced, there was no significant difference. IPAA was associated with improved long-term survival without an increase in postoperative complications. The risk of death after colectomy and IRA seemed to be predominantly related to the remaining risk of rectal cancer. Therefore, we favour proctocolectomy with IPAA as the prophylactic surgical procedure for FAP with intermediate or severe polyposis.

A systematic review and economic evaluation of diagnostic strategies for Lynch syndrome

BACKGROUND

Lynch syndrome (LS) is an inherited autosomal dominant disorder characterised by an increased risk of colorectal cancer (CRC) and other cancers, and caused by mutations in the deoxyribonucleic acid (DNA) mismatch repair genes.

OBJECTIVE

To evaluate the accuracy and cost-effectiveness of strategies to identify LS in newly diagnosed early-onset CRC patients (aged < 50 years). Cascade testing of relatives is employed in all strategies for individuals in whom LS is identified.

DATA SOURCES AND METHODS

Systematic reviews were conducted of the test accuracy of microsatellite instability (MSI) testing or immunohistochemistry (IHC) in individuals with CRC at risk of LS, and of economic evidence relating to diagnostic strategies for LS. Reviews were carried out in April 2012 (test accuracy); and in February 2012, repeated in February 2013 (economic evaluations). Databases searched included MEDLINE (1946 to April week 3, 2012), EMBASE (1980 to week 17, 2012) and Web of Science (inception to 30 April 2012), and risk of bias for test accuracy was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) quality appraisal tool. A de novo economic model of diagnostic strategies for LS was developed.

RESULTS

Inconsistencies in study designs precluded pooling of diagnostic test accuracy results from a previous systematic review and nine subsequent primary studies. These were of mixed quality, with significant methodological concerns identified for most. IHC and MSI can both play a part in diagnosing LS but neither is gold standard. No UK studies evaluated the cost-effectiveness of diagnosing and managing LS, although studies from other countries generally found some strategies to be cost-effective compared with no testing. The de novo model demonstrated that all strategies were cost-effective compared with no testing at a threshold of £20,000 per quality-adjusted life-year (QALY), with the most cost-effective strategy utilising MSI and BRAF testing [incremental cost-effectiveness ratio (ICER) = £5491 per QALY]. The maximum health benefit to the population of interest would be obtained using universal germline testing, but this would not be a cost-effective use of NHS resources compared with the next best strategy. When the age limit was raised from 50 to 60 and 70 years, the ICERs compared with no testing increased but remained below £20,000 per QALY (except for universal germline testing with an age limit of 70 years). The total net health benefit increased with the age limit as more individuals with LS were identified. Uncertainty was evaluated through univariate sensitivity analyses, which suggested that the parameters substantially affecting cost-effectiveness: were the risk of CRC for individuals with LS; the average number of relatives identified per index patient; the effectiveness of colonoscopy in preventing metachronous CRC; the cost of colonoscopy; the duration of the psychological impact of genetic testing on health-related quality of life (HRQoL); and the impact of prophylactic hysterectomy and bilateral salpingo-oophorectomy on HRQoL (this had the potential to make all testing strategies more expensive and less effective than no testing).

LIMITATIONS

The absence of high-quality data for the impact of prophylactic gynaecological surgery and the psychological impact of genetic testing on HRQoL is an acknowledged limitation.

CONCLUSIONS

Results suggest that reflex testing for LS in newly diagnosed CRC patients aged < 50 years is cost-effective. Such testing may also be cost-effective in newly diagnosed CRC patients aged < 60 or < 70 years. Results are subject to uncertainty due to a number of parameters, for some of which good estimates were not identified. We recommend future research to estimate the cost-effectiveness of testing for LS in individuals with newly diagnosed endometrial or ovarian cancer, and the inclusion of aspirin chemoprevention. Further research is required to accurately estimate the impact of interventions on HRQoL.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012002436.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Health behaviors in patients and families with hereditary colorectal cancer

It is estimated that 5 to 10% of all colorectal cancer (CRC) cases are attributed to a hereditary cause. The primary hereditary cancer syndromes that confer an increased risk for colorectal cancers are Lynch syndrome/hereditary nonpolyposis colorectal cancer (HNPCC) and familial adenomatous polyposis (FAP). Through genetic testing, health care providers can identify patients and families who carry gene mutations and subsequently are at a substantially greater risk for developing colorectal cancer than the general population. Genetic testing provides risk information not only about an individual patient, but also his or her biological relatives. A variety of risk-reduction behaviors (including screening, surgery, and health and lifestyle behaviors) have been examined in Lynch syndrome and FAP populations. The research indicates that screening behaviors are less than optimal, although the rates vary from study to study. Prophylactic colectomy is the primary course of treatment for individuals who test positive for a FAP mutation, but the results are inconclusive for cancer-unaffected Lynch syndrome mutation carriers. Although research suggests that the adoption of healthy lifestyles and behaviors (e.g., diet, physical activity, weight control, smoking cessation, limited alcohol consumption) could have a favorable impact on colon cancer burden, there is minimal data on how these behaviors may moderate cancer risk among those at risk of hereditary colon cancer. To date, we know very little about the actual health and lifestyle behaviors of those at risk of hereditary colon cancer. Genetic testing and counseling at risk individuals may resolve uncertainty about their personal and familial cancer risk and provide information to guide and personalize decisions about their future health care.

Healing of ileocolic nitinol compression anastomosis: a novel porcine model of subtotal colectomy

BACKGROUND

There are limited large animal models for the research of novel anastomotic technologies. Subtotal colectomy requires the anastomosis of relatively remote segments of the alimentary tract that are different anatomically, histologically, and pose significant physiological challenge. The quest for a foreign material-free anastomotic line reintroduced nitinol compression anastomosis into clinical use in the last decade.

OBJECTIVE

To evaluate the safety, histological, and physiological parameters of side-to-side ileocolic nitinol compression anastomosis in a newly developed large animal model, mimicking the human subtotal colectomy.

INTERVENTION

Resection of the entire spiral colon with an ileocolic side-to-side compression anastomosis in 12 animals, compared to resection of a short ileal segment in 6 animals. All anastomoses were constructed by using a novel nitinol-based compression device. The animals were followed up to 30 days postoperatively and were reoperated and sacrificed.

RESULTS

All 12 animals underwent successful subtotal colectomy with side-to-side nitinol compression anastomosis. No signs of abdominal infection were found. The increase in the colectomized animals' bodyweight over the postoperative course was significantly lower and the animals presented with longer periods of diarrhea. The histopathology revealed minimal inflammation and foreign body reaction with good alignment of the bowel wall layers in both groups. The anastomotic line width was shown to be reduced during the healing course of the compression anastomoses.

CONCLUSIONS

Side-to-side nitinol compression anastomosis is safe and demonstrates favorable functional and histopathological features. The porcine model of subtotal colectomy can be used for further research of novel anastomotic technologies.

Erkrankungen und Therapieformen des unteren Gastrointestinaltrakts

Duodenalatresien sind Hemmungsfehlbildungen und können proximal oder distal der Papilla Vateri entstehen, wobei die präpapillären Obstruktionen selten sind. Grundsätzlich kann zwischen einer Membranatresie und einer Defektatresie unterschieden werden. Die Unterscheidung beruht nicht nur auf embryologischen Gesichtspunkten, sondern hat auch eine klinische Bedeutung: Bei der Membranatresie kann die quergestellte, partiell offene oder geschlossene Membran weit in den distalen Duodenalanteil reichen („Windsackphänomen“), was zu diagnostischen und auch intraoperativen Problemen führen kann. Ein Pancreas anulare findet sich bei etwa 20 % aller Patienten mit Duodenalatresie.

Long-term results after restorative proctocolectomy with ileal pouch-anal anastomosis at a young age

BACKGROUND

Restorative proctocolectomy with IPAA is an optimal surgical treatment for patients with familial adenomatous polyposis and therapy resistant ulcerative colitis, few data are available on long-term results in patients who have undergone this operation at a young age.

OBJECTIVE

The aim of this study was to investigate long-term functional outcome, quality of life, body image, and sexual function after restorative proctocolectomy with IPAA in young patients with familial adenomatous polyposis or ulcerative colitis.

DESIGN, SETTINGS, AND PATIENTS

The study consisted of a retrospective review of medical records and questionnaire follow-up of 26 consecutive patients with familial adenomatous polyposis or ulcerative colitis who had undergone surgery between January 1992 and October 2008 at the Maastricht University Medical Center, were aged 10 to 24 years at the time of surgery, and had at least 1 year of follow-up after surgery.

MAIN OUTCOME MEASURES

We reviewed medical records from an institutional database regarding surgical procedures and short- and long-term complications. At the end of 2009, validated questionnaires covering bowel function (Colorectal Functional Outcome Questionnaire), quality of life (Short Form-36 and Gastrointestinal Quality of Life Index), body image and cosmesis (Body Image Questionnaire), and sexual function (International Index of Erectile Function for men and Female Sexual Function Index for women) were mailed to patients.

RESULTS

Median age at surgery was 18 years, and median follow-up was 12.5 (range, 2-18) years. Long-term colorectal complications occurred in 23 patients (88%), and were directly related to the surgery in 20 patients (77%). Five patients needed pouch excision. The questionnaire response rate was 88%. Bowel function, quality-of-life, and body image and cosmesis scores were all lower in patients than in historical normal control populations. Men did not report impotence or retrograde ejaculation, but 50% of women reported sexual dysfunction.

LIMITATIONS

This was a retrospective study in a small number of patients from a single institution with no comparison groups.

CONCLUSIONS

Restorative proctocolectomy with IPAA can be performed in young patients with an acceptable functional outcome, but at the cost of relatively high complication rates, poor body image and cosmesis, and a high rate of sexual dysfunction in women. Because young patients undergoing this surgical procedure may experience negative long-term effects, surgeons should be aware of all potential consequences, inform patients as to what to expect, and ensure long-term follow-up to deal with long-term complications.

Prevalence and phenotypes of APC and MUTYH mutations in patients with multiple colorectal adenomas

CONTEXT

Patients with multiple colorectal adenomas may carry germline mutations in the APC or MUTYH genes.

OBJECTIVES

To determine the prevalence of pathogenic APC and MUTYH mutations in patients with multiple colorectal adenomas who had undergone genetic testing and to compare the prevalence and clinical characteristics of APC and MUTYH mutation carriers.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study conducted among 8676 individuals who had undergone full gene sequencing and large rearrangement analysis of the APC gene and targeted sequence analysis for the 2 most common MUTYH mutations (Y179C and G396D) between 2004 and 2011. Individuals with either mutation underwent full MUTYH gene sequencing. APC and MUTYH mutation prevalence was evaluated by polyp burden; the clinical characteristics associated with a pathogenic mutation were evaluated using logistic regression analyses.

MAIN OUTCOME MEASURE

Prevalence of pathogenic mutations in APC and MUTYH genes.

RESULTS

Colorectal adenomas were reported in 7225 individuals; 1457 with classic polyposis (≥100 adenomas) and 3253 with attenuated polyposis (20-99 adenomas). The prevalence of pathogenic APC and biallelic MUTYH mutations was 95 of 119 (80% [95% CI, 71%-87%]) and 2 of 119 (2% [95% CI, 0.2%-6%]), respectively, among individuals with 1000 or more adenomas, 756 of 1338 (56% [95% CI, 54%-59%]) and 94 of 1338 (7% [95% CI, 6%-8%]) among those with 100 to 999 adenomas, 326 of 3253 (10% [95% CI, 9%-11%]) and 233 of 3253 (7% [95% CI, 6%-8%]) among those with 20 to 99 adenomas, and 50 of 970 (5% [95% CI, 4%-7%]) and 37 of 970 (4% [95% CI, 3%-5%]) among those with 10 to 19 adenomas. Adenoma count was strongly associated with a pathogenic mutation in multivariable analyses.

CONCLUSIONS

Among patients with multiple colorectal adenomas, pathogenic APC and MUTYH mutation prevalence varied considerably by adenoma count, including within those with a classic polyposis phenotype. APC mutations predominated in patients with classic polyposis, whereas prevalence of APC and MUTYH mutations was similar in attenuated polyposis. These findings require external validation.

Quality of life after surgery for colon cancer in patients with Lynch syndrome: partial versus subtotal colectomy

BACKGROUND

Lynch syndrome is a disorder caused by mismatch repair gene mutations. Mutation carriers have a high risk of developing colorectal cancer. In patients with Lynch syndrome in whom colon cancer has been diagnosed, in general, subtotal colectomy instead of partial colectomy is recommended because of the substantial risk of metachronous colorectal cancer. However, the effect of more extensive surgery on quality of life and functional outcome is unknown.

OBJECTIVE

The aim of this study was to investigate quality of life and functional outcome in patients with Lynch syndrome after partial colectomy and subtotal colectomy.

DESIGN

This is a nationwide cross-sectional study in the Netherlands.

SETTINGS

Two quality-of-life questionnaires (Short Form-36 and The European Organization for Research and Treatment of Cancer Colorectal Cancer-specific Quality of Life Questionnaire Module) and a functional outcome questionnaire (Colorectal Functional Outcome) were used.

PATIENTS

Patients with Lynch syndrome who underwent surgery for colon cancer were included.

MAIN OUTCOME MEASURES

The primary outcomes measured were quality of life and functional outcome.

RESULTS

Questionnaires were sent to 192 patients with Lynch syndrome who underwent surgery for colorectal cancer. A total of 136 patients returned the questionnaire (response rate, 71%). Eighteen patients with rectal cancer, 9 patients with a permanent ileostomy, and 5 patients with an IPAA were excluded. Fifty-one patients underwent partial colectomy, and 53 underwent subtotal colectomy. None of the scales of the Short Form-36 survey showed a significant difference. Analysis of the Colorectal Functional Outcome questionnaire revealed that, after subtotal colectomy, patients have a significantly higher stool frequency (p ≤ 0.01) and a significantly higher score on stool-related aspects (p = 0.06) and social impact (p = 0.03). The European Organization for Research and Treatment of Cancer Colorectal Cancer-specific Quality of Life Questionnaire Module presented more problems with defecation after subtotal colectomy (p ≤ 0.01).

LIMITATIONS

Certain selection bias cannot be ruled out.

CONCLUSIONS

Although functional outcome is worse after subtotal colectomy than after partial colectomy, generic quality of life does not differ after the 2 types of surgery in Lynch syndrome. When discussing the options for surgery with the patient, all advantages and disadvantages of both surgical procedures, including quality of life and functional outcome, should be discussed.

Surgical treatment of familial adenomatous polyposis: experience from a single institution in China

AIM

Surgical options for familiar adenomatous polyposis (FAP) have been standardized in developed countries but are still controversial in China. The aim of this study was to retrospectively evaluate the results of patients with FAP treated in a university hospital.

METHODS

In all 42 consecutive patients with FAP were operated on between May 1988 and June 2008. Median follow up was 7.2 years (2.2-20 years). Of these 33 patients were treated by proctocolectomy and ileal pouch anal anastomosis. A total colectomy with ileorectal anastomosis was undertaken in six and a proctocolectomy with ileostomy in three patients who had invasive rectal cancer.

RESULTS

Postoperative morbidity was insignificant. There were five wound infections, one intestinal obstruction, one anastomotic leakage, one anastomotic stenosis and one refractory pouchitis. One patient died from stroke. Five died from FAP-related disorders, namely, abdominal desmoids, liver metastases and advanced rectal cancer. Desmoid tumor occurred in five patients. Periampullary adenoma and carcinoma developed in four patients. In those with pouch procedure the 24-h bowel movement was 7.14 ± 1.28 (range 5-11) and their 10-year overall survival was 87.5%.

CONCLUSION

A proctocolectomy with ileal pouch anal anastomosis maybe the best choice for FAP patients in China. Surgical expertise, good teamwork and careful long-term follow up are mandatory.

Quality of life after restorative proctocolectomy and ileal pouch-anal anastomosis in patients with familial adenomatous polyposis: a matter of adjustment

AIM

Favourable outcomes for health-related quality of life (HRQL) have been reported in patients with familial adenomatous polyposis (FAP) after restorative proctocolectomy and ileal pouch-anal anastomosis (RPC). However, less is known about patients' subjective experience and adjustment to postoperative impairment. Using a multidimensional psychometric assessment, we investigated patient-reported HRQL to determine the impact of the patient's subjective experience together with medical, functional and psychosocial factors on HRQL.

METHOD

In this cross-sectional study, 116 FAP patients who had undergone RPC on average 8 years earlier completed standardized and study-specific questionnaires and participated in a personal interview. The impact of medical, functional and psychosocial factors on patients' HRQL was determined by regression analyses.

RESULTS

When using a generic psychometric measure, FAP patients' overall HRQL was comparable with that of the general population. Impaired HRQL, however, was found in patients reporting poor pouch function in contrast to those reporting good or moderate functional outcome. Findings from a personalized interview also suggested that a good functional result does not necessarily translate into good HRQL. Personal resources predicted patients' physical and psychological well-being, whereas little variance of HRQL was explained by medical factors and function.

CONCLUSION

Patients' HRQL is, to a substantial degree, the result of adjustment to the adverse impact of RPC. By using personal resources the majority of patients may achieve satisfactory HRQL levels even when bowel function is impaired. A multidimensional assessment that comprises medical, functional and psychosocial aspects is required to ascertain an adequate evaluation of FAP patients after RPC.

Quality of life and consequences for daily life of familial adenomatous polyposis (FAP) family members

AIM

The study aimed to document the impact of familial adenomatous polyposis (FAP) on health-related quality of life (HRQOL) and several practical aspects of daily life, and to identify factors significantly associated with HRQOL. This study is the first to compare HRQOL between patients with FAP, at-risk individuals and noncarriers.

METHOD

A total of 525 individuals (response rate 64%) from 145 families at high risk for FAP completed a battery of self-report questionnaires assessing generic- and condition-specific HRQOL and the consequences of FAP for daily life.

RESULTS

HRQOL was comparable to that of the general Dutch population. Surgically treated patients with FAP had significantly lower scores on several HRQOL domains compared with at-risk individuals, noncarriers and nonsurgically treated patients with FAP. Type of surgery was not significantly associated with HRQOL. Within the surgically treated group, postsurgical complications and comorbidity significantly affected HRQOL. Forty-one percent of patients reported that FAP had affected their working life.

CONCLUSION

Surgically treated patients with FAP have significantly poorer HRQOL than other groups. The type of surgery and age at time of first surgery were not associated with HRQOL but surgical complications and comorbidity were. Patients should be informed of the consequences of FAP for work and other life domains.

Health benefits and cost-effectiveness of primary genetic screening for Lynch syndrome in the general population

In current clinical practice, genetic testing to detect Lynch syndrome mutations ideally begins with diagnostic testing of an individual affected with cancer before offering predictive testing to at-risk relatives. An alternative strategy that warrants exploration involves screening unaffected individuals via demographic and family histories, and offering genetic testing to those individuals whose risks for carrying a mutation exceed a selected threshold. Whether this approach would improve health outcomes in a manner that is cost-effective relative to current standards of care has yet to be demonstrated. To do so, we developed a simulation framework that integrated models of colorectal and endometrial cancers with a 5-generation family history model to predict health and economic outcomes of 20 primary screening strategies (at a wide range of compliance levels) aimed at detecting individuals with mismatch repair gene mutations and their at-risk relatives. These strategies were characterized by (i) different screening ages for starting risk assessment and (ii) different risk thresholds above which to implement genetic testing. For each strategy, 100,000 simulated individuals, representative of the U.S. population, were followed from the age of 20, and the outcomes were compared with current practice. Findings indicated that risk assessment starting at ages 25, 30, or 35, followed by genetic testing of those with mutation risks exceeding 5%, reduced colorectal and endometrial cancer incidence in mutation carriers by approximately 12.4% and 8.8%, respectively. For a population of 100,000 individuals containing 392 mutation carriers, this strategy increased quality-adjusted life-years (QALY) by approximately 135 with an average cost-effectiveness ratio of $26,000 per QALY. The cost-effectiveness of screening for mismatch repair gene mutations is comparable to that of accepted cancer screening activities in the general population such as colorectal cancer screening, cervical cancer screening, and breast cancer screening. These results suggest that primary screening of individuals for mismatch repair gene mutations, starting with risk assessment between the ages of 25 and 35, followed by genetic testing of those whose risk exceeds 5%, is a strategy that could improve health outcomes in a cost-effective manner relative to current practice.

Colonic adenomatous polyposis syndromes: clinical management

Colorectal cancer is one of the major causes of cancer deaths in both men and women. It is estimated that 5 to 10% of patients with colorectal cancer have an inherited germline mutation that predisposes them to cancer. Hereditary colorectal cancer syndromes can be divided into those associated with colonic polyposis - familial adenomatous polyposis (FAP), attenuated familial adenomatous polyposis (aFAP), and MYH associated polyposis (MAP), and those not associated with colonic polyposis - hereditary nonpolyposis colon cancer (HNPCC). The hereditary polyposes are usually easier to diagnose than HNPCC, but their higher penetrance and variable phenotype pose some difficult problems in management and surveillance. The timing and type of surgical intervention, the management of desmoid risk, the treatment of rectal or pouch neoplasia, and the management of duodenal neoplasia are all questions that must be addressed in patients with FAP or MAP.

Evaluation of 28 years of surgical treatment of children and young adults with familial adenomatous polyposis

BACKGROUND

In this retrospective study, 28 years of surgical treatment of children and young adults with familial adenomatous polyposis (FAP) was analyzed.

METHODS

Forty-three patients were operated on before the age of 26 years. Endoscopic aspects, operative data, and complications were analyzed, and the resection specimens were reevaluated. Functional outcome was assessed by telephone questionnaire.

RESULTS

Primary ileorectal anastomosis (IRA) was performed in 34 patients with a mean age of 16 years (range, 7-25 years). Primary ileal-pouch anal anastomosis (IPAA) was performed in 9 patients at a mean age of 19 years (range, 15-24 years). Secondary excision of the rectum was performed in 7 patients. Overall, rectal carcinoma was present in 4 patients, at the age of 35, 36, 37, and 38 years. Two patients, aged 39 and 40 years, died because of invasive carcinoma with distant metastasis. The functional outcome and postoperative complications after both procedures were similar to those described in literature for children with FAP. Most patients did not experience alterations in lifestyle, and there was no urinary incontinence.

CONCLUSIONS

In this retrospective study, both IRA and IPAA showed to be feasible techniques in young patients with FAP. A prospective study with a sufficient follow-up is needed to compare both techniques in this specific group of patients.

Long-term outcome of metachronous rectal cancer following ileorectal anastomosis for familial adenomatous polyposis

BACKGROUND

Total colectomy with ileorectal anastomosis (IRA) for familial adenomatous polyposis (FAP) carries a potential risk of metachronous cancer in the residual rectum. This study evaluated the risk of cancer development in the residual rectum.

METHODS

Ninety-six patients who underwent initial surgery for prevention and cure of FAP were studied, and a clinicopathologic comparison was conducted between 59 patients who underwent IRA and 24 who underwent total proctocolectomy.

RESULTS

The 5-year overall survival rates were 94% after IRA and 95% after total proctocolectomy with no significant difference. The incidence of dense-type rectal polyps (4/17, 24%) was significantly higher in patients who developed metachronous rectal cancer following IRA compared to that in patients who did not (1/39, 3%). Moreover, 60% of patients with dense-type colon polyps developed metachronous rectal cancer compared to 24% in patients without and 80% of those with dense type rectal polyps developed metachronous rectal cancer compared to 25% without. Endoscopic surveillance of the eight Tis or T1 patients was performed at intervals of 6 months to 1 year after IRA but was not performed in three T3 patients for more than 2 years.

CONCLUSIONS

Effective IRA requires selection of patients without invasive rectal cancer and without dense rectal polyps in whom long-term postoperative follow-up of the residual rectum is possible.

Morbidity and quality of life after continent ileostomy in the Netherlands

BACKGROUND

Continent ileostomy (CI) after proctocolectomy is an alternative technique compared to an ileal pouch-anal anastomosis (IPAA). The question arises as to whether this technique is valuable. The aim of this study was to evaluate the role of the continent ileostomy, by patient follow-up satisfaction and quality of life assessment.

METHOD

Twenty-eight patients with a continent ileostomy operated between 1996 and 2007 were compared with patients who received an IPAA or a conventional ileostomy. SF-36 and EORTC QLC-CR38 questionnaires and a specific continent ileostomy questionnaire were used to assess differences and patient satisfaction.

RESULTS

The quality of life in patients with a CI is not significant better or worse than patients with either a conventional ileostomy or an IPAA. On three scales (sexual enjoyment, gastro-intestinal tract symptoms and male sexual problems) statistically significant differences were reported. Overall, nearly all patients are very satisfied with the CI. All patients would make the same decision again and would recommend this procedure to other patients.

CONCLUSION

The continent ileostomy remains to be a suitable alternative for the preservation of continence after a proctocolectomy, especially when an ileal pouch-anal anastomosis is not an option. If a choice has to be made between a CI and conventional ileostomy good preoperative counselling is necessary to make a well founded decision. To minimize complications, these procedures have to be performed in centres with specific expertise. Therefore, knowledge about the CI should be preserved for the future.

Psychosocial impact of familial adenomatous polyposis on young adults: a qualitative study

The aim of this study was to explore in detail the psychosocial impact of either having familial adenomatous polyposis (FAP) or being at risk for FAP amongst young adults. In-depth interviews were conducted with eleven individuals aged 18-35 with a clinical or genetic diagnosis of, or at risk of developing FAP. While being at risk did not seem to have a major psychosocial impact upon clinically unaffected participants, clinically affected individuals discussed a number of major stressors including issues in relation to changes in body image and physical functioning as a result of surgery, concerns about discussing FAP with new partners, difficulties in relation to childbearing decision-making, and impact on employment. Genetic counseling was described as being highly effective in providing support, but most participants were not aware of any other support services. Providing longer-term support through ongoing genetic counseling appears necessary to adequately address the ongoing challenges faced by young adults who are dealing with FAP.

Preoperative and postoperative quality of life in patients with familial adenomatous polyposis

PURPOSE

This study was designed to prospectively examine functional outcome, quality of life, and patients' personal experiences and adjustment to functional changes during the first year after prophylactic surgery.

METHODS

Twenty-one consecutive patients with familial adenomatous polyposis were examined before proctocolectomy (T0), on ileostomy reversal (T1), and 6 (T2) and 12 months (T3) after surgery by means of standardized questionnaires and interviews.

RESULTS

Average physical and mental health declined profoundly after proctocolectomy, followed by a steady improvement after 6 and 12 months. The majority of patients reported the ileostomy period as particularly distressing. After one year, 75 percent of patients reported complete recovery in terms of physical, emotional, and social functioning, whereas one-quarter of patients did not regain their former level of functioning. Despite substantial improvement in pouch functions, functional impairment persists because of frequent bowel movements, resulting mainly in restricted social activities. Ten percent of patients reported impaired sex life, irrespective of gender.

CONCLUSIONS

The majority of patients with familial adenomatous polyposis were found to adjust favorably to functional impairment while maintaining satisfactory quality of life. Complementing standardized quality of life measures by patients' personal experiences may help to identify vulnerable patients in need of psychosocial support.

Colectomy and ileorectal anastomosis is still an option for selected patients with familial adenomatous polyposis

PURPOSE

The risk of rectal cancer after colectomy and ileorectal anastomosis may be reduced in the last decades, as patients with severe polyposis now have an ileoanal pouch. We have reevaluated the risk of rectal cancer and proctectomy for all causes according to the year of operation.

METHODS

On the basis of the year of operation in 776 patients with ileorectal anastomosis and 471 pouch patients in Denmark, Finland, Holland, and Sweden, the "pouch period" was defined to start in 1990. Ileorectal anastomosis follow-up data was captured by May 31, 2006. The cumulative risk of rectal cancer and proctectomy was compared before and after 1990 by Kaplan-Meier analysis.

RESULTS

In the prepouch period 56/576 patients (10 percent) developed rectal cancer, vs. 4/200 (2 percent) in the pouch period. Neither the cumulative risk of rectal cancer (p = 0.07) nor the cumulative risk of proctectomy (p = 0.17) changed. However, in females the cumulative risk of rectal cancer (p = 0.04) and of proctectomy (p = 0.03) were lower in the pouch period.

CONCLUSIONS

Since the introduction of the ileoanal pouch rectal cancer has decreased after ileorectal anastomosis, but only statistically significant in females. This indicates that ileorectal anastomosis may still be justified in selected patients with mild adenomatosis, especially in young females.

Impact of familial adenomatous polyposis on young adults: quality of life outcomes

PURPOSE

This study used a novel questionnaire to assess quality of life and psychologic adjustment among young adults aged 18 to 35 years with a diagnosis of, or at risk of, developing familial adenomatous polyposis.

METHODS

Eighty-eight participants (25 males) were recruited through four Australian Hereditary Bowel Cancer Registries.

RESULTS

The average age of participants was 28 years, and the average age of these participants at the time of their last genetic consultation was 23 years. Seventy-one participants (81 percent) had clinical familial adenomatous polyposis, of whom 57 had undergone an ileorectal anastomosis or formation of an ileal pouch with anal anastomosis to prevent colorectal cancer. The ileal-pouch-with-anal-anastomosis group had significantly more adverse outcomes for physical functioning, body image, sexual impact, and negative affect compared with the no-surgery group -- and significantly more negative outcomes for physical functioning and negative affect compared with the ileorectal-anastomosis group. Among the total sample, a small proportion (11.4 percent) had avoidance scores indicative of a significant stress response, and being single was associated with higher levels of avoidance responses about familial adenomatous polyposis (z = -3.19; P = 0.001).

CONCLUSIONS

Familial adenomatous polyposis may have a negative impact across a broad range of life domains. Being single is an important risk factor for adverse psychologic outcomes. Delaying surgery, especially ileal pouch with anal anastomosis may minimize the negative impact on physical and psychologic functioning. Referral for psychologic intervention may be required for a small proportion of those affected by familial adenomatous polyposis, and ongoing access to genetic services may help to identify and address the needs of this group.

The impact of technical factors on outcome of restorative proctocolectomy for familial adenomatous polyposis

PURPOSE

This study was designed to assess the impact of technical factors on functional outcomes and complications in patients undergoing restorative proctocolectomy for familial adenomatous polyposis.

METHODS

This was a descriptive study on 189 patients undergoing restorative proctocolectomy in a single tertiary referral center between 1977 and 2003. Primary outcomes were major complications, pouch function, and neoplastic transformation in the anal transitional zone.

RESULTS

Pouch construction was J-reservoir (60 percent), W-reservoir (34 percent), or S-reservoir (6 percent), with double-stapled (31 percent) or handsewn anastomosis with mucosectomy (69 percent). Overall pouch survival was 96 percent at five years and 89 percent at ten years, with no differences according to pouch design or anastomotic technique. The incidence of pelvic sepsis was unaffected by anastomotic technique (stapled vs. handsewn; 12 vs. 13 percent) or type of reservoir (J- vs. W- vs. S-pouch; 16 vs. 9 vs. 10 percent). Fistula formation was independent of anastomotic technique (stapled vs. handsewn; 8 vs. 8 percent) and type of reservoir (J- vs. W- vs. S-pouch; 9 vs. 7 vs. 0 percent). The night-time and 24-hour bowel frequencies were similar with the two anastomotic techniques and types of reservoirs. The incidence of polyps at the anal transitional zone was lower with handsewn than with stapled anastomosis (19 vs. 38 percent; P=0.047).

CONCLUSIONS

Restorative proctocolectomy in patients with familial adenomatous polyposis has good functional outcomes and an acceptable rate of complications, which are independent of choice of technique. Handsewn ileoanal anastomosis with mucosectomy seems to reduce the incidence of subsequent neoplasia in the anal transitional zone but does not eliminate the risk of cancer.

[Familial adenomatous polyposis]

Familial adenomatous polyposis is a rare genetic disease characterized by the development of more than a hundred adenomatous polyps in the colorectal area, as well as by extracolonic manifestations. Without treatment, this inherited disease, usually transmitted by autosomal dominant inheritance, predisposes to colorectal cancer. Treatment must be preceded by counseling about the nature of the syndrome and by recommendations for the optimal management and surveillance of the disease. Currently, prophylactic surgical therapy is imperative. However, the type of surgical technique used depends mainly on the severity of the polyposis phenotype, the age of the patient at diagnosis, and a series of special clinical circumstances. Lifetime follow-up of all patients is required. This article reviews the main studies published on familial adenomatous polyposis in order to provide an update on the most appropriate management of these patients.

Restorative proctocolectomy and ileal pouch-anal anastomosis for familial adenomatous polyposis revisited

Since restorative proctocolectomy (RPC) with ileal-pouch anal anastomosis (IPAA) removes the entire diseased mucosa, it has become firmly established as the standard operative procedure of choice for familial adenomatous polyposis (FAP). Many technical controversies still persist, such as mesenteric lengthening techniques, close rectal wall proctectomy, endoanal mucosectomy vs. double stapled anastomosis, loop ileostomy omission and a laparoscopic approach. Despite the complexity of the operation, IPAA is safe (mortality: 0.5-1%), it carries an acceptable risk of non-life-threatening complications (10-25%), and it achieves good long-term functional outcome with excellent patient satisfaction (over 95%). In contrast to the high incidence in patients operated for ulcerative colitis (UC) (15-20%), the occurrence of pouchitis after IPAA seems to be rare in FAP patients (0-11%). Even after IPAA, FAP patients are still at risk of developing adenomas (and occasional adenocarcinomas), either in the anal canal (10-31%) or in the ileal pouch itself (8-62%), thus requiring lifelong endoscopic monitoring. IPAA operation does not jeopardise pregnancy and childbirth, but it does impair female fecundity and has a low risk of impairment of erection and ejaculation in young males. The latter can almost completely be avoided by a careful "close rectal wall" proctectomy technique. Some argue that low risk patients (e.g. <5 rectal polyps) can be identified where ileorectal anastomosis (IRA) might be reasonable. We feel that the risk of rectal cancer after IRA means that IPAA should be recommended for the vast majority of FAP patients. We accept that in some very selected cases, based on clinical and genetics data (and perhaps influenced by patient choice regarding female fecundity), a stepwise surgical strategy with a primary IPA followed at a later age by a secondary proctectomy with IPAA could be proposed.

Meta-analysis of observational studies of ileorectal versus ileal pouch-anal anastomosis for familial adenomatous polyposis

BACKGROUND

Surgery for familial adenomatous polyposis (FAP) aims to minimize cancer risk while providing good functional outcome. Colectomy with ileorectal anastomosis and proctocolectomy with ileal pouch-anal anastomosis both offer this, but there is no clear consensus about which is better.

METHODS

This is a meta-analysis of comparative studies published between 1991 and 2003 reporting early and late postoperative adverse events, functional outcomes and quality of life.

RESULTS

Twelve studies containing 1002 patients (53.4 per cent ileal pouch, 46.6 per cent ileorectal anastomosis) were identified. Bowel frequency (weighted mean difference 1.62 (95 per cent confidence interval (c.i.) 1.05 to 2.20)), night defaecation (odds ratio (OR) 6.64 (95 per cent c.i. 2.99 to 14.74)) and use of incontinence pads (OR 2.72 (95 per cent c.i. 1.02 to 7.23)) were significantly less in the ileorectal group, although faecal urgency was reduced with the ileal pouch (odds ratio 0.43 (95 per cent c.i. 0.23 to 0.80)). Reoperation within 30 days was more common after ileal pouch construction (23.4 versus 11.6 per cent; OR 2.11 (95 per cent c.i. 1.21 to 3.70)). There was no significant difference between the techniques in terms of sexual dysfunction, dietary restriction, or postoperative complications. Rectal cancer was a diagnosis only in the ileorectal group (5.5 per cent).

CONCLUSION

Ileal pouch and ileorectal anastomoses have individual merits. Further research is needed to determine which most benefits patients with FAP.

Prophylaktische Chirurgie der familiären adenomatösen Polyposis coli

Familial adenomatous polyposis coli (FAP) may not be considered a single disease entity with standardized guidelines for operative treatment. However, prophylactic colectomy after the manifestation of polyps but prior to the development of colorectal cancer is essential. The optimal timing of prophylactic surgery remains a clinical decision taken independently of mutation analysis. In case of the classic FAP phenotype, restorative proctocolectomy and ileal pouch-anal anastomosis is the procedure of choice. The development of reliable guidelines for attenuated FAP variants requires further evidence from clinical studies on surgical strategy and the advantages of prophylactic surgery over regular endoscopic screening with removal of polyps.

[Prophylactic surgery for hereditary non-polyposis colorectal cancer]

The most frequent hereditary colorectal cancer predisposition is Lynch syndrome, or hereditary non-polyposis colorectal cancer. The option of prophylactic surgery relies on the penetrance of the genetic defect and the heterogeneity of the condition. Since 20% of all mutation carriers never move on to develop cancer, the purely prophylactic setting is not indicated. However, when colorectal cancer is diagnosed, the question arises if the patient may benefit from extended surgery -- total colectomy or (restorative) proctocolectomy. These patients should be entered into the ongoing prospective-randomized study by German Cancer Aid (http://www.hnpcc-studie.de). Due to substantially increased cancer risk and poor surveillance options, the endometrium and stomach are also subject to the question of prophylactic intervention.

Quality of life after ileal pouch-anal anastomosis and ileorectal anastomosis in patients with familial adenomatous polyposis

PURPOSE

Differences in conventional outcomes such as functional results and the rate of complications have caused a controversy about whether the ileal pouch anal anastomosis or the ileorectal anastomosis is the preferred surgical treatment for patients with familial adenomatous polyposis. We therefore sought to ascertain not only the surgical results but also the perceptions of patients about their outcomes.

METHODS

Between 1981 and 1998, 152 patients at our institution had an ileal pouch-anal anastomosis and 32 patients had an ileorectal anastomosis for familial adenomatous polyposis. Of these 184 patients, 173 were sent a study-specific quality-of-life questionnaire and the Short Form 36 health survey to determine their health-related quality of life.

RESULTS

Ninety-four ileal pouch patients and 21 ileorectal patients returned the surveys. No difference was found in early postoperative complications, 5-year probability for complications, or functional results after either procedure. On the Short Form 36 health survey, the ileorectal patients had a lower mental health summary score compared with that of the ileal pouch patients but a similar physical health summary score. The study-specific questionnaire found both groups to have a comparable quality of life.

CONCLUSION

Because ileal pouch-anal anastomosis has the advantage of removing as much at-risk tissue as possible with similar functional results and better mental health, it may be considered the preferred operation for most patients with familial adenomatous polyposis.

Inherited colorectal cancer syndromes

Colorectal cancer is one of the major causes of cancer deaths in both men and women. It is estimated that approximately 5% to 10% of patients with colorectal cancer have an inherited germline mutation that predisposes them to cancer. Clinically, hereditary colorectal cancer syndromes can be divided into those associated with colonic polyposis (familial adenomatous polyposis, attenuated familial adenomatous polyposis, and MYH-associated polyposis) and those not associated with colonic polyposis (hereditary nonpolyposis colon cancer). Treatment options for these patients include multiple aggressive screening regimens, chemopreventive medications, and prophylactic surgery. Selection of the appropriate management approach is best made using information obtained from the patient's clinical examination, the family medical history, and genetic evaluation. Compliance is improved when patients completely understand their disease and participate fully in the formulation of the treatment plan. Although not proved, it seems reasonable that this approach may prevent the poor outcomes so frequently associated with inherited cancer syndromes.

In the beginning there was colectomy: current surgical options in familial adenomatous polyposis

Multiple colonic polyps, almost guaranteed colorectal cancer by the age of forty-five and an increased risk of non-colonic cancers characterise the autosomal dominant condition Familial Adenomatous Polyposis (FAP) [1]. The patients and families faced with such a diagnosis present many difficult management challenges, both surgical and non-surgical. We discuss the current surgical options for treatment of the more significant manifestations of FAP arising in the colorectum and duodenum as well as desmoid disease

Colorectal Cancer Screening and Treatment: Review of Outcomes Research

BACKGROUND

Colorectal cancer is the second leading cause of cancer deaths in the United States each year. Screening is effective in reducing colorectal cancer mortality; however, compliance with screening is poor, and factors associated with its compliance are poorly understood. The outcomes of treatment of colorectal cancer (surgery, radiation therapy, and chemotherapy) may have profound effects on quality of life (QOL). Furthermore, colorectal cancer screening and treatment may be expensive, and the costs are important from a policy perspective. This review examines patient-centered outcomes research related to colorectal cancer screening and treatment and outlines the work that has been done in several areas, including patient preferences, QOL, and economic analysis.

METHODS

The literature on the health outcomes associated with colorectal cancer screening and treatment was reviewed. A MEDLINE search of English language articles published from January 1, 1990 through February 2001, was conducted and was supplemented by a review of references of obtained articles. Criteria for study inclusion were identified a priori. A standardized data abstraction form was developed. Summary statistical analyses were performed on the results.

RESULTS

Six hundred eighty-six articles were selected for review. In total, 530 articles were excluded because they either did not include patient-centered outcomes, were duplicate articles, or could not be obtained. There were 156 articles included in the analysis; 67 addressed screening, 18 examined surveillance of high-risk groups, 22 concerned treatment of local disease, 10 examined treatment of local and metastatic disease, and 19 considered treatment of metastatic disease only. One study examined end-of-life care. In 19 studies, the phase of care was unspecified.

CONCLUSIONS

Standardized, disease-specific QOL instruments should be applied in clinical trials so that the results may be compared across different types of interventions. Valid and reliable methods that accurately capture patient preferences regarding screening and treatment should be developed.

Sexual function and continence after ileo pouch anal anastomosis: a comparison between a meta-analysis and a questionnaire survey

BACKGROUND AND AIMS

Ileo pouch anal anastomosis (IPAA) is the standard restorative procedure for patients with ulcerative colitis and familial adenomatous polyposis, but its pros and cons have not been explored in depth. This study analyzed the long-term complications such as incontinence and sexual dysfunction after IPAA.

PATIENTS AND METHODS

Netherlands Society for Crohn's disease and Ulcerative Colitis) A questionnaire on complications, sexual dysfunction, and continence was sent to all 137 members of the Netherlands Society for Crohn's disease and Ulcerative Colitis who had IPAA; the questionnaire was returned by 111. Results of the questionnaire were compared with those of a meta-analysis on pooled incidences of complications after IPAA, as previously performed and reported.

RESULTS

Pelvic sepsis was reported by 15.3% of respondents. The reported incidence of sexual dysfunction (19.8%), passive incontinence (23.4%), and soiling (39.3%) was significantly higher than that in the meta-analysis. Nevertheless, 90% of the population was satisfied with the results of the IPAA.

CONCLUSION

This study underlines that the operation itself, freeing patients of their disease, provides the major satisfaction and improvement of quality of life, even when patients have pouch-related complications such as sexual dysfunction and some degree of fecal incontinence.

Female fecundity before and after operation for familial adenomatous polyposis

BACKGROUND

Knowledge about the fertility of women suffering from familial adenomatous polyposis (FAP) is scarce and inconclusive. The purpose of this study was to investigate the fecundity of women with FAP before and after operation, and to compare the findings with those of a general population database and women with ulcerative colitis.

METHODS

A questionnaire concerning reproductive experiences and waiting times to pregnancy was sent to all 230 women on the polyposis registers in Denmark, Finland, Sweden and Norway in whom primary surgery had consisted of ileorectal anastomosis or ileal pouch-anal anastomosis. Data on the general population and women with ulcerative colitis came from an existing database. Cox regression and Kaplan-Meier plots were used for analysis.

RESULTS

The fecundity of women with FAP before operation and after colectomy with ileorectal anastomosis was similar to that of the general population. However, fecundity dropped to 54 per cent (P = 0.015) following proctocolectomy with ileal pouch-anal anastomosis, although it was greater than the postoperative fecundity of women with ulcerative colitis.

CONCLUSION

The significant reduction in female fecundity after ileal pouch-anal anastomosis should be communicated to young women with FAP before it is decided which surgical option to follow.

Patients with familial adenomatous polyposis experience better bowel function and quality of life after ileorectal anastomosis than after ileoanal pouch

OBJECTIVE

To evaluate the quality of life with emphasis on bowel function in patients undergoing either total colectomy with ileorectal anastomosis (IRA) or restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for familial adenomatous polyposis (FAP).

PATIENTS AND METHODS

All 151 patients operated on in our department between 1971 and 2000 were analysed retrospectively. Since 42 patients had to undergo reoperations, a total of 194 bowel procedures were performed. The final operative breakdown was: 48 IRA, 62 IPAA, 33 total proctocolectomies and 8 other procedures. By the end of the period under consideration, 40 patients had died, 28 had been lost to follow-up, 83 patients were still alive and of these 76 were analysed. Continence function and quality of life with emphasis on overall bowel function (Wexner (WS)-, Jostarndt (JS)-, Oresland (OS)- and Pemberton (PS)-scores) were recorded in 59 patients (22 IRA and 37 IAP).

RESULTS

Continence and bowel function were significantly better after IRA than after IPAA (mean scores: WS, 1.1 vs 5.4, P=0.001; JS, 32.5 vs 24.7, P=0.0001; OS, 2.9 vs 7.9, P=0.0001), as was quality of life (PS, 25.6 vs 19.6, P=0.001). The mean values for each single item of all 4 scores were consistently better after IRA. Neither gender, age nor type of pouch-anal anastomosis (stapled vs hand-sewn) had a significant influence on outcome. IPAA patients with uneventful follow-up (n = 27) had better mean values for all 4 scores (WS, 4.2 vs 7.3; JS, 26.1 vs 23.1; PS, 20.4 vs 17.7; OS, 6.6 vs 9.9) than those with postoperative complications (n = 10; 27%), but statistical significance was reached only in the OS (P = 0.026). No such difference was seen after IRA (14% complication rate).

CONCLUSION

The significantly better continence after IRA resulting in superior patient comfort and quality of life must be balanced against the oncological disadvantage of this procedure. On the basis of large patient population studies, genotype-phenotype correlations with respect to the risk for rectal cancer may need to be taken into account. Postoperative complications may have a lasting negative effect on outcome after IPAA.

Effect of sphincter-sacrificing surgery for rectal carcinoma on quality of life in Muslim patients

PURPOSE

Living with a permanent colostomy significantly diminishes a patient's quality of life. However, little is known about its influence on worship patterns in Muslims. Therefore, the aim of this study was to assess the quality of life in Muslim patients after surgery for rectal carcinoma, especially with respect to religious worship.

METHODS

We studied 178 patients who had undergone curative surgery for colorectal carcinoma. The patients fell into three groups based on the type of surgery they underwent: abdominoperineal resection (n = 75), sphincter-saving resection (n = 51), and anterior resection including sigmoid colectomy (n = 52). Quality of life was measured with the Medical Outcomes Study Short Form 36 Health Survey and a questionnaire that asked participants about their work responsibilities, sexual life, and religious worship.

RESULTS

The scores for all eight subscales of the Short Form 36 in the abdominoperineal resection group were significantly poorer than those in the sphincter-saving resection and anterior resection groups ( P< 0.001). In addition, social life and work responsibilities were significantly more affected in the abdominoperineal resection group than in the other two groups ( P< 0.001). A significantly ( P< 0.001) greater number of patients in the abdominoperineal resection group stopped praying daily (either alone or in a mosque) and fasting during Ramadan.

CONCLUSION

Two aspects of religious worship (praying and fasting) were significantly impaired in the Muslim patients who had a stoma as a result of sphincter-sacrificing surgery. To improve quality of life in these patients, religious issues as they relate to the presence of a stoma should be discussed during preoperative counseling, the informed consent process, and counseling with local religious authorities.

Quality of life in patients undergoing ileal pouch-anal anastomosis at the University of Cincinnati

BACKGROUND

In 1978, Drs. Fischer and Martin were among the first to preserve anorectal continence and create a pelvic reservoir in adult patients, in what has become the ileal pouch-anal anastomosis (IPAA).

METHODS

Here we review our institutions' experience with 379 of these procedures from 1978 to present. To assess the specific health concerns of patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP) and determine the effects of IPAA on health-related quality of life, we evaluated patients with the SF-36, the Rating Form of Inflammatory Bowel Disease Patient Concerns (RFIPC), time trade-off questions, and a gamble question.

RESULTS

IPAA patients did not differ from the general population in seven of eight general health categories assessed by the SF-36. When compared with the UC population as a whole using the RFIPC they had reduced concerns in almost all areas. In addition, time trade-off and gamble questions indicated that these patients, as a group, are willing to accept a significant risk of dying in order to achieve their results of the IPAA.

CONCLUSIONS

This high level of satisfaction has led to the referral of patients who would not have otherwise considered a procedure requiring permanent ileostomy.