Faculty Bibliography

PURPOSE: Surgical intervention for toxic ulcerative colitis in pregnancy is associated with a high morbidity and mortality for both mother and her fetus. A limited surgical procedure may be desirable to reduce the risk of maternal and fetal mortality. We describe the use of "blowhole" colostomy and loop ileostomy (Turnbull procedure) in the management of toxic dilation of the colon complicating ulcerative colitis in pregnancy. METHODS: The medical records of two pregnant females with toxic ulcerative colitis were reviewed. The presentations, management, and outcomes of these patients and their neonates are described. RESULTS: The Turnbull-Blowhole colostomy and ileostomy was used in the acute management of toxic ulcerative colitis in two pregnant females. Both mothers and neonates had successful outcomes with resolution of the acute process. Completion proctocolectomy and ileal pouch-anal anastomosis was later performed in both patients. CONCLUSIONS: The colonic decompression and fecal diversion procedure provided minimal operative trauma to the mother and fetus and resulted in successful outcome in the management of toxic ulcerative colitis in pregnancy. We believe the procedure is safe, effective, and relatively simple, which may reduce the morbidity and mortality of toxic colitis in pregnancy.

PURPOSE: Stapling of the ileal pouch-anal anastomosis with preservation of the anal transitional zone remains controversial because of concerns about the potential risk of dysplasia and cancer. The natural history and optimal treatment of anal transitional zone dysplasia ten or more years after surgery are unknown. This study establishes the risk of dysplasia in the anal transitional zone and the outcome of a conservative management policy for anal transitional zone dysplasia, with a minimum of ten years' follow-up after ileal pouch-anal anastomosis. METHODS: A total of 289 patients undergoing anal transitional zone-sparing stapled ileal pouch-anal anastomosis for inflammatory bowel disease between 1986 and 1990 were studied. Patients undergoing anal transitional zone-sparing ileal pouch-anal anastomosis who were studied with serial anal transitional zone biopsies for at least ten years postoperatively were included (n = 178). Median follow-up was 130 (range, 120-157) months. RESULTS: Anal transitional zone dysplasia developed in 8 patients 4 to 123 (median, 9) months after surgery. There was no association with gender, age, preoperative disease duration, or extent of colitis, but the risk of anal transitional zone dysplasia was significantly associated with cancer or dysplasia as a preoperative diagnosis or in the proctocolectomy specimen. Dysplasia was high grade in two patients and low grade in six. Two patients with low-grade dysplasia on two or more occasions after detection of low-grade dysplasia underwent completion mucosectomy and perineal pouch advancement with neo-ileal pouch-anal anastomosis. One patient with high-grade dysplasia on two occasions was to undergo completion mucosectomy, but this was not technically feasible. Partial mucosectomy with vigorous anal transitional zone biopsy was performed with close postoperative surveillance. Biopsies were negative for dysplasia. The second recently diagnosed patient with high-grade dysplasia underwent examination under anesthesia with negative anal transitional zone biopsies and will be kept under close surveillance. No cancer in the anal transitional zone was found during the study period. The 4 other patients with low-grade dysplasia on 1 or 2 occasions were treated expectantly and have been dysplasia free for a median of 119 (range, 103-133) months. CONCLUSIONS: Anal transitional zone dysplasia after stapled ileal pouch-anal anastomosis is infrequent and is usually self-limiting. Anal transitional zone preservation did not lead to the development of cancer in the anal transitional zone with a minimum of ten years of follow-up. Long-term surveillance is recommended to monitor dysplasia. If repeat biopsy confirms persistent dysplasia, mucosectomy with perineal pouch advancement and neo-ileal pouch-anal anastomosis is recommended.

BACKGROUND AND AIMS: Peutz-Jeghers syndrome (PJS) is a rare, autosomal-dominant disease characterized by hamartomatous polyps of the alimentary tract, hyperpigmentation of the skin, and family history of PJS. Rarely, solitary Peutz-Jeghers polyps (PJP) arise in patients without other features of PJS. PATIENTS AND METHODS: We reviewed eight patients since 1979 with solitary PJP, six men and two women. RESULTS: The average age at diagnosis was higher (56+/-13 years) than that of PJS patients in the literature. Polyps were found in the sigmoid colon ( n=4), cecum ( n=1), stomach ( n=1), and duodenum ( n=2). The colonic polyps were diagnosed and removed endoscopically. Indications for colonoscopy included routine screening ( n=4) or rectal bleeding ( n=1). The duodenal and gastric polyps were diagnosed and removed during gastroduodenoscopic examinations, which were performed for nonspecific dyspepsia ( n=2) or gastrointestinal bleeding ( n=1). The median size was 20 mm (range 2 mm-25 mm). Patients were followed for a median of 11.5 years (range 3-22) without another PJP or cancer. Three patients died of causes unrelated to PJP. Five patients are alive and polyp free. CONCLUSION: Solitary PJP do not carry a risk of gastrointestinal cancer and are not an indication for specific high-risk screening.

BACKGROUND: Restorative proctocolectomy (RP) has been the surgical procedure of choice for surgical management of mucosal ulcerative colitis since 1978. This study was undertaken to investigate the clinical presentation and implications of portal vein thrombi (PVT). METHODS: We reviewed all patients undergoing RP in our institution in the 4 years from January 1997 to December 2000. As the diagnosis of PVT was made on computed tomography (CT) scan in all cases, we confined our incidence estimate to those patients having an abdominal CT scan postoperatively. All scans were reviewed by an experienced radiologist. Patient demographics, symptoms, and clinical course were recorded. RESULTS: A total of 702 patients underwent RP, of whom 94 had a CT scan within the postoperative period. PVT was diagnosed in 42 of the 94 patients (45%). PVT was diagnosed at initial reading of the scan in 11 patients, and on review in 31. The indications for CT scan included abdominal pain, fever, leukocytosis, and delayed bowel function. Septic complications of RP caused these symptoms and signs in 45 patients, 20 of whom had PVT. Twenty-two patients were found to have had PVT without evidence of any septic source. CONCLUSION: PVT can be found in a high proportion of patients undergoing abdominal CT scan after RP. It is often associated with pain, fever, nausea vomiting, tenderness, and leukocytosis. This study shows that PVT subtle enough to go undiagnosed has no serious consequences, even when not treated. Also, patients treated with anticoagulation recover completely.

Massive presacral hemorrhage following rectal mobilization for benign or malignant conditions is an uncommon complication but one that is alarming and often difficult to treat. A variety of methods of hemostasis have been described, all with mixed degrees of success. We have used a segment of free rectus abdominis muscle to provide tamponade to the presacral bleeding point in two patients with severe bleeding. The technique was successful and may be considered in cases of problematic hemorrhage when other techniques have failed or inapplicable.

OBJECTIVE: To compare the function, complications, and quality of life after ileal pouch-anal anastomosis (IPAA) for patients with indeterminate colitis (IndC) and ulcerative colitis (UC). SUMMARY BACKGROUND DATA: Reports on the outcome of IPAA for IndC have been inconclusive because of the small numbers available for analysis. Concerns about functional outcome, infectious perineal complications, pouch loss and the development of Crohn's disease remain, while there is no data on the quality of life after IPAA for IndC. METHODS: One thousand nine hundred and eleven patients undergoing IPAA for Ind and UC from 1983 to 1999 were evaluated. IndC was confirmed by repeat pathologic evaluation in 115 patients. Functional outcome and quality of life were assessed prospectively for all office visits (IndC = 230; UC = 5388) using previously reported systems. Complications were evaluated retrospectively. RESULTS: Functional results and the incidence of anastomotic complications and major pouch fistulae were the same in UC and IndC patients. Although IndC patients were more likely to develop minor perineal fistulae, pelvic abscess, and Crohn's disease, the rate of pouch failure was 3.4%, identical to that of UC patients. There was no clinically significant difference in quality of life, or satisfaction with IPAA surgery. Patients were equally happy to recommend surgery to IndC or UC patients, but 3% fewer IndC would undergo the same surgery again for their disease. CONCLUSIONS: While functional outcome, quality of life, and pouch survival rates are equivalent after IPAA for IndC and UC, there is an increase in some complications and the late diagnosis of Crohn's disease. Over 93% of IndC patients would undergo the same procedure again, and 98% would recommend IPAA to others with IndC. Patients with IndC should not be precluded from having IPAA surgery.

PURPOSE: Concerns about morbidity and functional outcome have lead some authors to suggest that ileal pouch-anal anastomosis should not be performed in older patients. This article evaluates the outcome of selected septuagenarians undergoing ileal pouch-anal anastomosis at this institution. METHODS: Seventeen of 1,911 patients undergoing ileal pouch-anal anastomosis for ulcerative colitis were older than the age of 70 at the time of surgery. Functional outcome, quality of life, and manometric data were assessed prospectively, whereas complications were assessed by chart review. RESULTS: There was one mortality related to sepsis after small-bowel obstruction and one reoperation at 18 months for pelvic abscess. Minor complications occurred in five patients. Median (interquartile range) quality of life and health and levels of energy and happiness (scored out of 10) were 9 (7-10), 9 (7-10), 8 (5-10), and 9.5 (7-10), respectively. Medical Outcomes Study Short Form 36 quality of life scores were not different from those for the healthy population older than 65 years. There was complete continence in 38 percent, rare incontinence in 12 percent, and some incontinence in 50 percent. Nobody was usually or always incontinent. Overall, 82 percent would undergo pouch surgery again, and 89 percent would recommend it to others. CONCLUSIONS: Ileal pouch-anal anastomosis is an acceptable surgical option for selected healthy, motivated septuagenarians with ulcerative colitis who are eager to preserve fecal continence.

PURPOSE: As an alternative to resection, strictureplasty may allow for preservation of intestinal length and avoidance of short-bowel syndrome in patients with diffuse Crohn's jejunoileitis. However, the long-term durability of the procedure and its safety have not been confirmed. The purpose of this study was to report our experience with strictureplasty for diffuse Crohn's jejunoileitis. METHODS: Between 1984 and 1999, 123 patients underwent a laparotomy that included an index strictureplasty for diffuse jejunoileitis. Patient history, operative details, and postoperative morbidities were obtained by chart review. Nineteen patients (15 percent) were receiving total parenteral nutrition for short-bowel syndrome, and 81 (66 percent) were taking chronic steroids. Total number of strictureplasties performed was 701 (median, 5/patient). Seventy percent of patients underwent a synchronous bowel resection. Follow-up information was determined by personal or phone interviews. Recurrence was defined as the need for reoperation, and risk was calculated by the Kaplan-Meier method. Patients with diffuse jejunoileitis were also compared with 219 patients with limited small-bowel Crohn's disease undergoing strictureplasty. RESULTS: The overall morbidity rate was 20 percent, with septic complications occurring in 6 percent. The surgical recurrence rate was 29 percent with a median follow-up period of 6.7 (range, 1-16) years. The recurrence rate in diffuse jejunoileitis patients did not differ from that seen in patients with limited small-bowel Crohn's disease (P = 0.38). Short duration of disease and short interval since last surgery were significant predictors of accelerated recurrence (P = 0.008 and 0.04, respectively). CONCLUSIONS: Strictureplasty is a safe and durable alternative to resection in diffuse Crohn's jejunoileitis. Patients with a short duration of disease and short interval since last surgery are at higher risk for accelerated recurrence. Patients with diffuse jejunoileitis do not appear to be at higher risk for recurrence than patients with more limited Crohn's disease.

The purpose of this study was to determine whether perioperative manometry is useful in predicting long-term functional status after ileal pouch-anal anastomosis (IPAA). Prospectively collected perioperative anal manometry data from 1439 patients undergoing IPAA from 1986 to 2000 were compared to postoperative functional status at various time intervals from 6 months to 8 years after IPAA. A validated questionnaire was used to obtain information regarding restrictions of diet, work, social and sexual activity, urgency, fecal seepage or incontinence, energy level, satisfaction with surgery, and quality of life. The presence of seepage and the degree of incontinence were compared to the patient's perceived quality of life, health, energy level, and satisfaction with surgery. Low (<40 mm Hg) pre- and postoperative resting pressures were associated with increased seepage, pad use, and incontinence. Patients with low resting pressures also reported diminished quality of life, health, energy level, and satisfaction with surgery. There was a significant association (P < 0.001) between seepage and degree of incontinence and quality of health, quality of life, energy level, and level of satisfaction with surgery. Perioperative resting anal sphincter pressures greater than 40 mm Hg are associated with significantly better function and quality of life after ileal IPAA. Improved functional outcome is associated with better quality-of-life outcomes. Low preoperative resting pressures do not preclude successful outcome after IPAA.

OBJECTIVE: Pouchitis often is diagnosed based on symptoms alone. However, increased stool frequency, urgency, and abdominal pain could be due to a condition resembling irritable bowel syndrome. This study was designed to assess the etiology of bowel symptoms using the Pouchitis Disease Activity Index (PDAI). METHODS: Symptoms, endoscopy, and histology were assessed in 61 consecutive symptomatic patients with ulcerative colitis after ileal pouch-anal anastomosis. Pouchitis was defined as a PDAI score of > or = 7, cuffitis was defined as endoscopic and histological inflammation of the rectal cuff and no inflammation of the pouch, and irritable pouch syndrome (IPS) was defined as symptoms with a PDAI of <7 and the absence of cuffitis. RESULTS: Thirty-one patients (50.8%) had pouchitis, four (6.5%) had cuffitis, and 26 (42.6%) had IPS. Demographics were similar in the three groups. Increased stool frequency, urgency, and abdominal cramps were the most common symptoms in the three groups. Rectal bleeding was seen only in cuffitis (p < 0.001). No patient in the three groups had fever. Twenty-seven patients (87.1%) with pouchitis responded to a 2-wk course of ciprofloxacin or metronidazole with a reduction in PDAI scores of > or = 3. All four patients with cuffitis responded to topical hydrocortisone or mesalamine with a reduction in the PDAI symptom component score of > or = 1. Twelve patients with IPS (46.2%) responded to antidiarrheal, anticholinergic, and/or antidepressant therapies with a reduction in the PDAI symptom component score of > or = 1, whereas the remaining patients had persistent symptoms despite therapy. CONCLUSIONS: A substantial number of symptomatic patients after ileal pouch-anal anastomosis do not meet the diagnostic criteria for either pouchitis or cuffitis and have been classified as having IPS. There is an overlap of symptoms among patients with pouchitis, cuffitis, and IPS, and endoscopic evaluation can differentiate among these groups. Distinction between these three groups has therapeutic implications.