Is ileoproctostomy a reasonable procedure after total abdominal colectomy?

Prospective evaluation of quality of life and sexual functioning after laparoscopic total mesorectal excision

PURPOSE

This study was designed to investigate how the quality of life of patients with rectal cancer changes with time after laparoscopic total mesorectal excision.

METHODS

Patients completed the Medical Outcomes Study Short Form 36 and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire and a colorectal-specific European Organisation for Research and Treatment of Cancer quality of life questionnaire before laparoscopic total mesorectal excision, on discharge from the hospital and at 3, 6, and 12 months postoperatively. Patients were treated by laparoscopic low anterior resection or laparoscopic abdominoperineal resection.

RESULTS

Fifty-one patients (mean age, 64 years; 29 males (57 percent)) participated in this study, of whom 38 (75 percent) underwent laparoscopic low anterior resection and 13 (25 percent) laparoscopic abdominoperineal resection. Compared with preoperative scores on the Medical Outcomes Study Short Form 36, patients reported a deterioration in physical functioning (74 vs. 80; P = 0.009), and improved mental functioning (76 vs. 70; P = 0.007) at three months. Improvement in emotional well-being was reported both on the Medical Outcomes Study Short Form 36 (78 vs. 53; P = 0.006) and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (84 vs. 69; P < 0.001). At one year, improvements in global quality of life (82 vs. 68; P = 0.001) and symptoms, such as fatigue (18 vs. 32; P < 0.001), pain (5 vs. 12; P = 0.009), and appetite loss (3 vs. 13; P = 0.01), were reported. Sexual functioning was worse from three months onward until one year after surgery (47 vs. 66; P = 0.004). Patients who underwent low anterior resection experienced less sexual dysfunction than patients after abdominoperineal resection (21 vs. 56; P = 0.004).

CONCLUSIONS

One year after laparoscopic total mesorectal excision for rectal cancer, patients reported improvement in some important quality of life outcomes, including global quality of life, despite a decrease in sexual functioning.

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

BACKGROUND

Knowledge of postoperative health status is important in decision-making about the type of operation necessary in patients with familial adenomatous polyposis (FAP). This study compared the quality of life (QoL) between patients with an ileorectal anastomosis (group 1) and those with an ileal pouch-anal anastomosis (group 2).

METHODS

QoL was assessed with both a generic questionnaire (Short Form-36 Health Survey; SF-36) and a disease-specific questionnaire (European Organization for Research and Treatment of Cancer Colorectal QoL Questionnaire; EORTC QLQ-CR38). The SF-36 consists of 36 items representing eight generic health domains, and the EORTC QLQ-CR38 comprises 38 items representing disease-specific health domains. Both questionnaires were distributed among 323 patients with FAP known at the Dutch Polyposis Registry who had previously undergone either operation. The results of the SF-36 were compared with the scores of age- and sex-matched respondents from the general population.

RESULTS

Some 279 patients (86 per cent), 161 in group 1 and 118 in group 2, completed the questionnaire. Generic and disease-specific QoL was the same for groups 1 and 2. The SF-36 scores of both groups were significantly lower than those of the general population.

CONCLUSION

There were no differences with respect to health status between patients in groups 1 and 2, and preference for either procedure cannot be based on QoL.

Clinical outcome and bowel function following total abdominal colectomy and ileorectal anastomosis in the Oriental population

Total abdominal colectomy with ileorectal anastomosis is a commonly performed surgical procedure. The postoperative outcome of these patients, however, has not been studied in detail in the Asian population.

AIM

The purpose of this study was to analyze the functional outcome of patients following total abdominal colectomy and ileorectal anastomosis.

METHOD

All patients subjected to a total abdominal colectomy with ileorectal anastomosis during a six-year period from February 1989 to October 1995 were reviewed.

RESULTS

Sixty-six patients (male:female, 40:26) with a mean age of 55.2 (range, 20-88) years underwent total abdominal colectomy with ileorectal anastomosis. Median follow-up after surgery was 26 (range, 4-78) months. Indications for surgery were synchronous or metachronous tumors (18), complicated pancolonic diverticular disease (15), obstructed tumors with impending perforation (13), familial adenomatous polyposis (7), slow-transit constipation (6), and others (7). Mean operative time was 137 +/- 48 minutes. Mean postoperative hospitalization was 13.3 +/- 11.9 days. Time to first bowel movement and commencement of solid diet were 4.7 +/- 1.8 and 7.2 +/- 2.4 days, respectively. Four patients had prolonged postoperative ileus. Average stool frequencies per day were 5.5 at one week, 4.3 at one month, 3.9 at six months, 3.2 at one year, and 2.9 at two years postoperatively. Thirty-three patients (50 percent) required antidiarrheal treatment for a transient period, but none required long-term therapy. Ninety-seven percent of all patients rated the functional outcome as good to excellent, and 3 percent said it was fair. There was two perioperative mortalities. Five cases required re-laparotomy, three for anastomotic complications and two for hemoperitoneum. Five patients had recurrent admissions for adhesion colic, which resolved with nonsurgical therapy. Ten patients succumbed on follow-up, six to tumor recurrence, two to unrelated cancers (stomach and bladder), and three to medical conditions.

CONCLUSION

The functional outcome of ileorectal anastomosis is generally rated as good to excellent by patients. Acceptable bowel function and control is regained within six months of the operation and levels off at one year after surgery, and no patient requires long-term antidiarrheal medication.

Factors influencing bowel function following total abdominal colectomy

PURPOSE

The purpose of this study was to determine which factors influenced bowel function following total abdominal colectomy.

METHODS

Thirty-two patients who had undergone total abdominal colectomy were studied with regard to factors that are classically thought to influence bowel function, namely, residual stump length, transit time, and rectal stump manometry. In a limited subset of patients, anal manometry was done also.

RESULTS

Transit time was the best predictor of bowel function following total abdominal colectomy. This was followed by stump length. If transit time was short, then stump length became important in predicting the occurrence of diarrhea following total abdominal colectomy.

CONCLUSIONS

Two factors have an important influence on bowel function following total abdominal colectomy: transit time and rectal stump length. Rectal stump length is an anatomic factor that can be controlled by the surgeon. In total abdominal colectomy, rectal stump length of at least 20 cm is necessary if the patient is to have satisfactory postoperative bowel function. This may not always be possible. In these patients, modification of diet to influence transit time and methods to increase rectal compliance will be necessary.

The NSAID sulindac reverses rectal adenomas in colectomized patients with familial adenomatous polyposis: clinical results of a dose-finding study on rectal sulindac administration

After colectomy with ileorectal anastomosis (IRA) for treatment of familial adenomatous polyposis (FAP), the rectal mucosa remains, with the risk of malignant change. Locoregional (rectal) sulindac has been applied, with initial higher-dose therapy and subsequent low-dose maintenance therapy to minimise side-effects. The dose-finding study with sulindac suppositories started with a dose of 300 mg sulindac daily per patient over 6 weeks. Depending on proctoscopical evaluation of regression of polyposis, sulindac doses were reduced in predefined steps. Ten of 15 patients developed a complete remission following 42 weeks of treatment, while the rest had partial remission. Responses were recorded 6-24 weeks after beginning sulindac treatment. After 36 weeks, 13/15 patients received 25-50 mg sulindac daily. An increase in the number of partial remissions after 42 weeks of treatment at doses of 100 mg sulindac daily may indicate the first approach to a reduced dose between 100 mg to 25 mg sulindac daily, but may also point to the importance of long-term treatment rather than dose-intense therapy.

Ileorectostomy in the older patient

Surgeons have always been wary of performing abdominal colectomy and ileorectostomy in the older patient for fear of excessive stool frequency and fecal incontinence. Thirty-two patients, aged 60 years or over, underwent abdominal colectomy and ileorectostomy and were closely questioned regarding their preoperative, early postoperative, and late postoperative bowel habits. These patients were compared with a group of age- and sex-matched controls who had undergone right hemicolectomy. In both groups, the ileocecal valve had been resected, but only the ileorectostomy group had the entire colon resected. Immediately after ileorectostomy, patients underwent an average increase in bowel movements of 3.6 movements per day. This gradually decreased over time, so that, after five years, older patients with ileorectostomy had an average of 1.5 more bowel movements per day than they had had preoperatively. There were similar increases in the right hemicolectomy patient group: 0.9 bowel movements per day immediately after right hemicolectomy and 0.2 bowel movements per day after five years. Incontinence was an uncommon problem in both groups. This study suggests that elderly patients undergoing abdominal colectomy and ileorectostomy have an increase in daily bowel movements, which is not solely attributable to the loss of the right colon. However, it is a procedure that is well tolerated, with a low risk of incontinence and only a mild increase in stool frequency.