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Clinical approach to diseases of ileal pouch-anal anastomosis
Shen, Bo; Fazio, Victor W; Remzi, Feza H; Lashner, Bret A
Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for ulcerative colitis (UC) patients with medically refractory disease or dysplasia. IPAA significantly improves quality of life in UC patients who require surgery. However, certain inflammatory and noninflammatory diseases can develop after the surgery, including pouchitis, Crohn's disease of the pouch, cuffitis, and irritable pouch syndrome. The etiology and pathogenesis of these disease conditions of IPAA are largely unknown. Accurate diagnosis and classification are important for appropriate management. Endoscopic evaluation is the most important tool for the diagnosis and differential diagnosis.
PMID: 16393238
ISSN: 0002-9270
CID: 2156652
Hartmann's reversal is associated with high postoperative adverse events
Aydin, H Nail; Remzi, Feza H; Tekkis, Paris P; Fazio, Victor W
PURPOSE: The aim of this study was to ascertain the preva lence and pattern of surgical and medical adverse events in patients undergoing Hartmann's reversal for diverticular dis ease. A comparison of postoperative outcomes is made be tween Hartmann's reversal and primary resection and anas tomosis. METHODS: Data were collected from patients who underwent successful Hartmann's reversal (Group 1 n=121) and primary resection and anastomosis (Group 2 n=731) for diverticular disease in a single center from January 1981 to May 2003. Multivariate logistic regression was used to compare early postoperative mortality, medical and surgical complications and readmission rates between the two groups. RESULTS: Hartmann's reversal was associ ated with a higher prevalence of surgical or medical com plications compared with primary resection and anastomo sis (43.8 percent and 9.1 percent for Hartmann's reversal vs. 26.0 percent and 4.8 percent for primary resection and anastomosis). There was no difference in the readmissior rates (7.2 percent vs. 7.6 percent, respectively, P = 0.88) or early postoperative mortality (1.7 percent vs. 0.7 percent, P = 0.25) between Hartmann's reversal and primary resection and anastomosis. The need for reoperation, prolonged ileus respiratory tract infections, and renal failure were more common adverse events in the Hartmann's reversal group (P < 0.01). Having controlled for the number of comorbid conditions, extent of diverticular disease, severity of peri toneal contamination (Mannheim Peritonitis Index), and op erative urgency, patients who underwent Hartmann's rever sal were 2.1 times more likely to have adverse surgical events during their postoperative period (95 percent confidence interval for odds ratio = 1.3-3.3). CONCLUSIONS: Hartmann's reversal is a complex surgical procedure that is associated with a high prevalence of postoperative adverse events in comparison with primary resection and anastomosis. To minimize the prevalence of such adverse events, patients who undergo Hartmann's reversal need careful preoperative evaluation and close monitoring in their postoperative period.
PMID: 16228835
ISSN: 0012-3706
CID: 2156672
Surgical outcome in patients with primary sclerosing cholangitis undergoing ileal pouch-anal anastomosis: a case-control study
Gorgun, Emre; Remzi, Feza H; Manilich, Elena; Preen, Miriam; Shen, Bo; Fazio, Victor W
BACKGROUND: The outcome of restorative proctocolectomy in the setting of chronic ulcerative colitis complicated by primary sclerosing cholangitis (PSC) is not clear. The purpose of this study was to determine the surgical outcome, risk of dysplasia/cancer, morbidity/mortality, long-term results, and functional and quality of life results in patients with inflammatory bowel disease (IBD) and PSC who underwent restorative proctocolectomy with ileal pouch-anal anastomosis and compare them in a case-matched study. METHODS: Patients with PSC-associated IBD undergoing restorative proctocolectomy between 1983 and 2002 were included in the study. This study group was matched for age, gender, diagnosis, duration of disease, anastomosis technique, and proximal diversion to a cohort of IBD patients with no associated PSC who underwent restorative proctocolectomy during the same period of time. Postoperative morbidity, incidence of neoplasia/cancer in the resected specimen, pouchitis, pouch failure, long-term mortality, and 5-year survival rates were compared between the groups. The functional and quality of life records were prospectively collected and compared between the groups. For each group, matched Kaplan-Meier survival analysis was also conducted comparing 5-year survival between the 2 cohorts, matching for diagnosis, duration of disease, age, gender, anastomosis type, and proximal diversion. RESULTS: Sixty-five patients with PSC and IBD underwent restorative proctocolectomy with ileal pouch-anal anastomosis during the study period. Two hundred sixty IBD patients with no associated PSC who matched with the outlined criteria comprised the control group. The follow-up period was 68 +/- 50 months for the PSC group and 102 +/- 62 months for the control group. A higher incidence of cancer (14% vs 5%, P = .02) and dysplasia in the resected specimen (40% vs 7%, P < .001), an associated increased risk of postoperative pelvic sepsis (14% vs 5%, P = .02), and higher long-term mortality (35% vs 4%, P < .001) were found in the PSC group compared with control group with no associated PSC. The majority, 13 of 23 (57%), of the deaths in the PSC group were a result of liver disease. Five-year survival for the PSC group was significantly poorer than the 5-year survival for the control group with no associated PSC. No significant differences were found in functional and quality of life results between the groups in the short- and long-term follow-up periods. CONCLUSIONS: PSC-associated IBD patients after restorative proctocolectomy have a higher risk of neoplasia/cancer in the resected specimen, postoperative pelvic sepsis, and higher long-term mortality. Functional and quality of life remains similar in IBD patients after restorative proctocolectomy with or without associated PSC in the follow-up. However, patients with IBD and PSC have a significantly poorer survival than patients with no associated PSC after restorative proctocolectomy.
PMID: 16269291
ISSN: 0039-6060
CID: 2156662
Vaginal delivery after ileal pouch-anal anastomosis: a word of caution
Remzi, Feza H; Gorgun, Emre; Bast, Jane; Schroeder, Tom; Hammel, Jeffrey; Philipson, Elliot; Hull, Tracy L; Church, James M; Fazio, Victor W
PURPOSE: This study was designed to evaluate the impact of childbirth on anal sphincter integrity and function, functional outcome, and quality of life in females with restorative proctocolectomy and ileal pouch-anal anastomosis. METHODS: The patients who had at least one live birth after ileal pouch-anal anastomosis were asked to return for a comprehensive assessment. They were asked to complete the following questionnaires: the Short Form-36, Cleveland Global Quality of Life scale, American Society of Colorectal Surgeons fecal incontinence severity index, and time trade-off method. Additionally, anal sphincter integrity (endosonography) and manometric pressures were measured by a medical physician blinded to the delivery technique. Anal sphincter physiology also was evaluated with electromyography and pudendal nerve function by nerve terminal motor latency technique. RESULTS: Of 110 eligible females who had at least one live birth after ileal pouch-anal anastomosis, 57 participated in the study by returning for clinical evaluation to the clinic and 25 others by returning the quality of life and functional outcome questionnaires. Patients were classified into two groups: patients who had only cesarean section delivery after ileal pouch-anal anastomosis (n = 62) and patients who had at least one vaginal delivery after ileal pouch-anal anastomosis (n = 20). The mean follow-up from the date of the most recent delivery was 4.9 years. The vaginal delivery group had significantly higher incidence of an anterior sphincter defect by anal endosonography (50 percent) vs. cesarean section delivery group (13 percent; P = 0.012). The mean squeeze anal pressure was significantly higher in the patients who had only cesarean section delivery (150 mmHg) after restorative proctocolectomy than patients who had at least one vaginal delivery (120 mmHg) after restorative proctocolectomy (P = 0.049). Quality of life evaluated by time trade-off method also was significantly better in the cesarean section delivery group (1) vs. vaginal delivery group (0.9; P < 0.001). CONCLUSIONS: The risk of the sphincter injury and quality of life measured by time trade-off method are significantly worse after vaginal delivery compared with cesarean section in patients with ileal pouch-anal anastomosis. In the short-term, this does not seem to substantially influence pouch function or quality of life; however, the long-term effects remain unknown, thus obstetric concern may not be the only factor dictating the type of delivery in this group of patients. A planned cesarean section may eliminate these potential and factual concerns in ileal pouch-anal anastomosis patients.
PMID: 16142432
ISSN: 0012-3706
CID: 2156682
Quality of life, functional outcome, and complications of coloplasty pouch after low anterior resection
Remzi, Feza H; Fazio, Victor W; Gorgun, Emre; Zutshi, Massarat; Church, James M; Lavery, Ian C; Hull, Tracy L
PURPOSE: The colonic J-pouch has been used to improve bowel function in patients undergoing low colorectal or coloanal anastomosis. However, a narrow pelvis, difficulties in reach, a long anal canal with prominent sphincters, or a fatty mesentery may turn this technique into a technically challenging procedure in certain patients. In these circumstances, "coloplasty" offers an alternative to a straight anastomosis. The purpose of this study was to compare the quality of life, functional outcome, and complications between patients undergoing coloplasty, colonic J-pouch, or straight anastomosis. METHODS: Altogether, 162 patients who underwent coloanal or low colorectal anastomosis between 1998 and 2001 were studied. Data collected included demographics, length of follow-up, technique and type of anastomosis, complications, quality of life, and functional outcome. Results were analyzed according to use of a coloplasty (n = 69), colonic J-pouch (n = 43), or straight anastomosis (n = 50). The choice of the technique was based on the surgeon's preference. Usually coloplasty or straight anastomosis was favored in male patients with a narrow pelvis or when a handsewn anastomosis was used. RESULTS: Quality of life assessment with the short form-36 questionnaire revealed better scores in coloplasty and colonic J-pouch groups. The coloplasty (1.0 +/- 1.7) and colonic J-pouch (1.0 +/- 1.2) groups had fewer night bowel movements than the straight anastomosis group (1.5 +/- 2.0) (P < 0.05). The coloplasty group also had fewer bowel movements per day than the straight anastomosis group (3.8 +/- 2.9 vs. 4.8 +/- 3.6; P < 0.05); also, less clustering and less antidiarrheal medication use were observed than in the straight anastomosis group. Colonic J-pouch patients with handsewn anastomosis had a higher anastomotic leak rate (44 percent) than the patients in the coloplasty with handsewn anastomosis group (3.6 percent). CONCLUSIONS: Coloplasty seems to be a safe, effective technique for improving the outcome of low colorectal or coloanal anastomosis. It is especially applicable when a colonic J-pouch anastomosis is technically difficult.
PMID: 15785900
ISSN: 0012-3706
CID: 2156692
Recurrence after transanal excision of T1 rectal cancer: should we be concerned?
Madbouly, Khaled M; Remzi, Feza H; Erkek, Bulent A; Senagore, Anthony J; Baeslach, Christen M; Khandwala, Farah; Fazio, Victor W; Lavery, Ian C
PURPOSE: Transanal excision is an appealing treatment for low rectal cancers because of its low morbidity, mortality, and better functional results than transabdominal procedures. However, controversy exists about whether it compromises the potential for cure. Several, recent reports of high recurrence rates after local excision prompted us to review our results of transanal excision alone in patients with T1 rectal cancers. METHODS: All patients with T1 low rectal cancer undergoing local excision alone between 1980 through 1998 were reviewed for local recurrence, distant metastasis, disease-free interval, results of salvage surgery, and overall and disease-free survival. Demographics, tumor size, distance from anal verge, and preoperative endoluminal ultrasound results also were recorded. Patients with poorly differentiated tumors, perineural or lymphovascular invasion, or with mucinous component were excluded. RESULTS: Fifty-two patients underwent transanal excision during the study period. Five-year recurrence was estimated to be 29.38 percent (95 percent confidence interval, 15.39-43.48). For 52 patients, five-year, cancer-specific and overall survival rates were 89 and 75 percent respectively. Fourteen of 15 patients with recurrence underwent salvage treatment with 56.2 percent (95 percent confidence interval, 35.2-90) five-year survival rate. Gender, preoperative staging by endorectal ultrasound, distance from the anal verge, tumor size, location, and T1 status discovered after transanal excision of a villous adenoma did not influence local recurrence or tumor-specific survival. CONCLUSIONS: Transanal excision for T1 rectal tumors with low-grade malignancy has a high rate of recurrence. Although overall cancer survival rates might be regarded as satisfactory, this high recurrence and low salvage rate raises the issue about the role of transanal excision alone for early rectal cancer and the possible need for adjuvant therapy or increased role of resective surgery.
PMID: 15768186
ISSN: 0012-3706
CID: 2156702
Loop ileostomy closure after restorative proctocolectomy: outcome in 1,504 patients
Wong, Kutt-Sing; Remzi, Feza H; Gorgun, Emre; Arrigain, Susana; Church, James M; Preen, Miriam; Fazio, Victor W
PURPOSE: Routine use of a temporary loop ileostomy for diversion after restorative proctocolectomy is controversial because of reported morbidity associated with its creation and closure. This study intended to review our experience with loop ileostomy closure after restorative proctocolectomy and determine the complication rates. In addition, complication rates between handsewn and stapled closures were compared. METHODS: Our Department Pelvic Pouch Database was queried and charts reviewed for all patients who had ileostomy closure after restorative proctocolectomy from August 1983 to March 2002. RESULTS: A total of 1,504 patients underwent ileostomy closure after restorative proctocolectomy during a 19-year period. The median length of hospitalization was three (range, 1-40) days and the overall complication rate was 11.4 percent. Complications included small-bowel obstruction (6.4 percent), wound infection (1.5 percent), abdominal septic complications (1 percent), and enterocutaneous fistulas (0.6 percent). Handsewn closure was performed in 1,278 patients (85 percent) and stapled closure in 226 (15 percent). No significant differences in complication rates and length of hospitalization were found between handsewn and stapled closure techniques. CONCLUSIONS: Our results demonstrated that ileostomy closure after restorative proctocolectomy can be achieved with a low morbidity and a short hospitalization stay. In addition, we found that complication rates and length of hospitalization were similar between handsewn and stapled closures.
PMID: 15714246
ISSN: 0012-3706
CID: 2156712
Evaluation of the learning curve in ileal pouch-anal anastomosis surgery
Tekkis, Paris P; Fazio, Victor W; Lavery, Ian C; Remzi, Feza H; Senagore, Antony J; Wu, James S; Strong, Scott A; Poloneicki, Jan D; Hull, Tracy L; Church, James M
SUMMARY BACKGROUND DATA: We define the learning curve required to attain satisfactory training in ileal pouch-anal anastomosis (IPAA) and identify possible differences in the learning curve for stapled and hand-sewn IPAA surgery. Various studies have addressed the differences in failure rate between stapled and hand-sewn IPAA, but there is no literature that evaluates the differences in attaining satisfactory training in each of these techniques. METHODS: Data were collected from 1965 patients undergoing IPAA surgery by 12 surgeons in a single center between 1983 and 2001. Using ileoanal pouch failure as the primary end point, a parametric survival model was used to adjust for case mix (patient comorbidity, preoperative diagnosis, manometric findings, and prior anal pathology). A risk-adjusted cumulative sum (CUSUM) model was used for monitoring outcomes in IPAA surgery. RESULTS: The 5-year ileal pouch survival was 95.6% (median patient follow-up of 4.2 years; range 0-19 years). Fifty percent of trainee staff demonstrated a learning curve in IPAA surgery. Having adjusted for case mix, trainee staff undertaking stapled IPAA surgery showed an improvement in the pouch failure rate following an initial training period of 23 cases versus 40 cases for senior staff. The learning curve for hand-sewn IPAA surgery was quantified only for senior staff who attained adequate results following an initial period of 31 procedures. CONCLUSIONS: The CUSUM method was a useful tool for objectively measuring performance during the learning phase of IPAA surgery. With adequate training, supervision, and monitoring, the learning curve in IPAA surgery may be reduced even further.
PMCID:1356911
PMID: 15650636
ISSN: 0003-4932
CID: 2156752
Colonic surgery in patients with juvenile polyposis syndrome: a case series
Oncel, Mustafa; Church, James M; Remzi, Feza H; Fazio, Victor W
PURPOSE: Juvenile polyposis syndrome is characterized by multiple hamartomatous polyps in the large intestine. When indicated, the surgical choices in symptomatic juvenile polyposis syndrome patients are colectomy with ileorectal anastomosis or proctocolectomy with pouch. The aim of this study was to evaluate the long-term outcomes of the surgical options in juvenile polyposis syndrome patients who present with symptomatic colonic polyps. METHODS: The charts of all juvenile polyposis syndrome patients who had had at least one colonic operation since 1953 in our institution were reviewed. The following data were abstracted: demographics, the number and site of the polyps, symptoms, the intervals and types of the colonic operation, follow-up, and the patients' current status. RESULTS: There were 13 patients (6 males) with a median age of 10 years (range, 1-50 years) at the time of diagnosis. Patients had colonic (n = 13), rectal (n = 12), and gastric (n = 6) polyps. Rectal bleeding (n = 11) was the most common presenting symptom. Three patients underwent proctectomy as the initial operation. Although a rectum-preserving operation was initially performed in ten patients, a subsequent proctectomy was required in five of them within a median of 9 years (range, 6-34 years). Therefore, eight patients had their rectum removed during the study period; five had an ileal pouch-anal anastomosis, one had a Koch pouch as a restorative surgery, and two had an end ileostomy. No relation was observed between the number of colonic and rectal polyps and the type of surgery or the need for proctectomy. Patients were followed up a median of 3 years (range, 2-24 years) after their ultimate operations. During this period, one patient (20 percent) who underwent restorative proctectomy and 4 patients (80 percent) whose rectums were preserved required multiple endoscopic polypectomies for recurrent polyps in the pouch (first patient) or their rectums (the other four patients). The patient who underwent the Koch procedure required surgery for recurrent polyps in her pouch. CONCLUSIONS: One-half of the patients who initially underwent rectal preservation required subsequent proctectomy. The number of colonic or rectal polyps does not influence the choice of the surgical procedure. Both restorative proctocolectomy and subtotal colectomy with ileorectal anastomosis need endoscopic follow-up because of the high recurrence rates of juvenile polyps in the remnant rectum or pouch.
PMID: 15690657
ISSN: 0012-3706
CID: 2156722
Comprehensive evaluation of inflammatory and noninflammatory sequelae of ileal pouch-anal anastomoses
Shen, Bo; Fazio, Victor W; Remzi, Feza H; Delaney, Conor P; Bennett, Ana E; Achkar, Jean-Paul; Brzezinski, Aaron; Khandwala, Farah; Liu, Wendy; Bambrick, Marlene L; Bast, Jane; Lashner, Bret
BACKGROUND AND AIMS: Ileal pouch-anal anastomosis (IPAA) improves quality of life (QOL) for ulcerative colitis patients who require surgery. Crohn's disease (CD) of the pouch, pouchitis, cuffitis, and irritable pouch syndrome (IPS) have an adverse impact on physical and psychological well-being, which can compromise the gain in QOL after the surgery. Their clinical, endoscopic, and histologic features have not been fully characterized. The aim of this study was to compare demographic, clinical, endoscopic, and histologic features between CD of the pouch, pouchitis, cuffitis, IPS, and normal pouches. METHODS We enrolled 124 patients: normal pouches (N = 26), CD of the pouch (N = 23), pouchitis (N = 22), cuffitis (N = 21), and IPS (N = 32). Symptomatology, endoscopy, histology, and the Cleveland Global QOL and the Irritable Bowel Syndrome-QOL scores were compared among the groups. RESULTS: Univariate analysis of demographic and clinical data showed a possible association between NSAID use and pouchitis, extraintestinal manifestation and cuffitis, and antidepressant use and IPS. There were no differences in the Pouchitis Disease Activity Index symptom scores between the disease groups, with an exception of bleeding, which occurred almost exclusively in cuffitis. Endoscopy was useful in discriminating between CD of the pouch, pouchitis, cuffitis, and normal pouches or IPS. Patients with diseased IPAA had worse QOL scores. CONCLUSIONS: Symptoms largely overlapped among the disease groups of IPAA. Endoscopy is valuable for diagnosis. Inflammatory or noninflammatory sequelae of IPAA adversely affected patients' QOL.
PMID: 15654787
ISSN: 0002-9270
CID: 2156742