Allopurinol as prophylaxis against pouchitis following ileal pouch-anal anastomosis for ulcerative colitis. A randomized placebo-controlled double-blind study.

BACKGROUND: Pouchitis is the major long-term complication of restorative proctocolectomy for ulcerative colitis (UC). Allopurinol is a scavenger of oxygen-derived free radicals, which it is suggested play a role in the development of UC and pouchitis. The first aim was to test the hypothesis that the incidence of pouchitis can be reduced by prophylactic Allopurinol, and secondly to evaluate if Allopurinol influences the overall pouch function. METHODS: 273 patients with UC who were planned for proctocolectomy and ileal pouch-anal anastomosis at 12 centres in Sweden between October 1994 and June 1997 were offered the opportunity to participate. 184 patients (67%) were randomized to receive postoperative prophylactic Allopurinol 100 mg twice daily or placebo. All 273 patients had clinical and endoscopic follow-up at 1, 3, 6, 12, 18, 24 months after surgery. RESULTS: Of the 184 randomized patients, 94 were randomized to Allopurinol and 90 to placebo; 116 patients (63%) completed follow-up and the crude incidence of pouchitis among those patients fullfilling the protocol was 31% in the Allopurinol group and 28% in the placebo group (ns). The cumulative risk for a first attack of pouchitis was 30% and 26% after 24 months (ns). The overall pouch function improved over time and did not differ significantly between the two groups. CONCLUSIONS: Prophylactic Allopurinol did not reduce the risk of a first attack of pouchitis.

Stapled ileoanal pouches without loop ileostomy: a prospective study in 86 patients.

In restorative proctocolectomy the use of a stapling technique to construct an ileal pouch with anal anastomosis offers an alternative to the hand-sewn technique following mucosectomy; a temporary defunctioning loop ileostomy may reduce the consequences of an anastomotic leakage, however it may entail discomfort for the patient, an additional operation, possible complications, and longer total hospital stay. This prospective study evaluated the peri- and postoperative courses in 86 consecutive, referred patients receiving ileal pouch-anal anastomosis using the stapling technique to construct the ileal pouch and ileoanal anastomosis, omitting the defunctioning loop ileostomy except in cases of increased risk of ileoanal anastomotic insufficiency according to defined criteria. Follow-up time was 36-96 months. Patients undergoing primary loop ileostomy stayed a median of 19 days in hospital, as opposed to a median of 9 days in those who did not. Eight patients developed pelvic sepsis that demanded a secondary defunctioning loop ileostomy, and five showed symptoms arising from relapsing inflammation in residual rectal mucosa; in three of these, a secondary transanal mucosectomy covered by a loop ileostomy was necessary. During the follow-up period ten patients had bowel obstructions that demanded surgery; two developed late pouch-vaginal fistulas, and one a fistula from the J-limb to the abdominal scar. There was one case of pouch procidentia. At 12-month follow-up the median evacuation frequency was 6 per 24 h, the incidence of minor incontinence was about 10%, and urgency to evacuate occurred in about 10%. None of the patients experienced any major incontinence. The stapling technique and omission of the defunctioning loop ileostomy in restorative proctocolectomy were thus a comparatively reliable and time-saving method with short total hospital stay. In patients at increased risk of anastomotic complications, however, a defunctioning loop ileostomy is recommended. We believe it is important to perform an exact dissection into the anal canal to avoid a residual rectal mucosa that may be inflamed or even become dysplastic.

Gains and losses with stapling and omission of loop ileostomy in pelvic pouch surgery: a matched control study.

After 10 years experience of pelvic pouch surgery with handsewn pouch and ileoanal anastomosis, mucosectomy, and covering loop ileostomy, the surgical technique was altered. Twenty patients were operated on with staple technique in pouch and ileoanal anastomosis but without mucosal proctectomy and loop ileostomy. This study group was compared with a matched control group of patients from our previous series with respect to duration of surgery, blood loss, hospital stay, complications, and functional outcome after 2 months, 12 months, and 60 months. It was found that staple technique significantly reduced the duration of surgery and the need of blood transfusions. Length of hospital stay after pouch surgery did not differ between the two groups, but omitting loop ileostomy reduced total hospital stay by about 2 weeks. Ileoanal anastomotic insufficiency occurred in two patients in the study group. Treatment by establishment of a defunctioning loop ileostomy, local saline perfusion, and administration of antibiotics was successful; the anastomosis healed within 2 weeks, and the longterm functional outcome did not differ from the average. Increased temperature persisted postoperatively in seven patients in the study group. Transient peroneal paresis occurred in three patients in the control group. Only in the control group was there stenosis in the ileoanal anastomosis requiring dilatation and fibrosis at the levator plane demanding emptying by a catheter. Concerning functional outcome, nighttime continence was significantly better in the study group than in the control group. The evacuation rate per 24 h was significantly higher in the study group after 2 and 12 months but not after 60 months. The outcome concerning other functional parameters such as urgency to evacuate, capacity to discriminate between gas and stool, deferral time, and perianal symptoms, did not differ significantly. Staple technique without mucosal proctectomy and loop ileostomy thus results in shorter duration of surgery and shorter hospital stay. In patients with increased risk of insufficiency of the anastomosis, however, covering loop ileostomy may be justified because of the risk for more serious consequences if anastomotic leakage occurs.

Biofeedback retraining in patients with functional constipation and paradoxical puborectalis contraction: comparison of anal manometry and sphincter electromyography for feedback.

PURPOSE: This study was undertaken to assess the effect of biofeedback therapy in patients with constipation and paradoxical puborectalis contraction and to compare two different feedback modes. METHODS: Twenty-six patients were randomly allocated to either of two feedback modes: anal pressure using a manometry probe or anal sphincter electromyography (EMG) using surface electrodes. RESULTS: Six patients were unable to complete their training; ten patients were retrained using anal manometry and ten patients using EMG. The paradoxical puborectalis contraction disappeared after retraining with manometry feedback in eight of ten patients and with EMG feedback in ten of ten patients. A significant improvement in both bowel function and abdominal symptoms was found after training and a continued improvement at follow-up six months later. Six patients in the manometry group and nine in the EMG group experienced an overall improvement in symptoms. The two feedback methods did not differ in terms of efficacy. CONCLUSIONS: Our results suggest that biofeedback, using either manometry or EMG, is effective in improving symptoms and anorectal function caused by paradoxical puborectalis contraction.

Neoplastic transformation of the pelvic pouch mucosa in patients with ulcerative colitis.

BACKGROUND & AIMS: Some patients with ulcerative colitis (UC) receiving an ileal pelvic pouch with ileoanal anastomosis (IPAA) develop persistent severe villous atrophy in the pouch mucosa. To investigate if mucosal atrophy indicates a risk for subsequent neoplastic transformation of the ileal pouch mucosa, a follow-up study was undertaken. METHODS: Seven patients with UC and an IPAA in whom persistent severe atrophy (type C) developed and 14 control patients with no or only slight atrophy (type A) were prospectively surveyed by flexible videoendoscopy with multiple biopsies for assessment of possible neoplastic changes. RESULTS: The median time of the pouch in function was 9 years for both groups. Dysplasia was found in 5 of 7 patients in the type C group (71%) compared with none in the type A group (P < 0.001). Four patients had low-grade dysplasia, and 1 patient had sequential multifocal development into high-grade dysplasia. Multifocal DNA aneuploidy was found in 2 patients, 1 with low-grade and 1 with high-grade dysplasia. CONCLUSIONS: Patients with UC and a long-standing IPAA who develop persistent severe mucosal atrophy are at risk also of neoplastic transformation of the pouch mucosa.

Pouchitis following pelvic pouch operation for ulcerative colitis. Incidence, cumulative risk, and risk factors.

AIM: This study was undertaken to assess the risk for pouchitis in patients with ulcerative colitis who underwent surgery with colectomy, restorative pelvic pouch, and ileoanal anastomosis and to evaluate possible factors predictive for pouchitis development. PATIENTS AND METHODS: All patients receiving a pelvic pouch because of ulcerative colitis at Huddinge University Hospital between 1980 and 1993 (n = 149; 89 men) were prospectively evaluated for symptoms suggestive of pouchitis. Diagnosis of pouchitis was based on occurrence of certain symptoms in combination with endoscopic findings. Pouchitis was divided into mild and severe, and the time span until the first attack of mild or severe pouchitis was calculated for each patient. RESULTS: Median follow-up time was 54 (5-152) months. The absolute cumulative risk of developing mild pouchitis was 21, 26, and 39 percent at 6, 12, and 48 months, respectively. The corresponding cumulative risk of developing severe pouchitis was 9, 11, and 14 percent, respectively. Risk for both groups together was 51 percent at 48 months. The occurrence of pouchitis, calculated at six-month intervals after closure of the loop ileostomy, was highest (23.1 percent) during the first six months. Incidence during the next six-month period was 11.4 percent and then only 3.1 percent thereafter. Thirty-two patients (21.5 percent) had chronic continuous symptoms requiring long-term metronidazole treatment, and 14 (9.4 percent) of those had chronic severe pouchitis. In two patients, removal of the pouch and permanent ileostomy became necessary. Extracolonic manifestations and early onset of ulcerative colitis were predictive factors for developing pouchitis. Former smoking seemed to be a protective factor. CONCLUSION: The risk for pouchitis was highest during the initial six-month period. Cumulative risk leveled off after two years but was substantial (51 percent) at four years. Less than 10 percent of patients had severe, chronic pouchitis, and only two patients (1.3 percent) had their pouches removed.

Ileoanal anastomosis with pelvic pouch: short review.

Pelvic pouch surgery is still a rather new technique, but has been developed considerably over the years. The construction of J-shaped pouches and ileoanal anastomoses with a total stapling technique has meant considerable progress in the operative procedure compared to the method including mucosal proctectomy en bloc with excision of the rectum and colon, handsewn pouches, and handsewn ileoanal anastomoses. Omission of a deviating loop ileostomy saves the patient another operation, hospital stay and sick leave. Development of malignancy in an atrophic pouch mucosa cannot be ruled out. Careful surveillance of all patients at the operating clinic is therefore necessary.

Pelvic pouch-anal anastomoses: pros and cons about omission of mucosectomy and loop ileostomy. A study of 60 patients.

Pelvic pouches were constructed in 60 consecutive patients from 1987 to 1991. The first 30 patients underwent mucosectomy and construction of handsewn reservoirs, and ileoanal anastomoses protected by loop ileostomy (group A). In the following 12 patients (group B1) J pouches and ileoanal anastomoses were constructed by total stapling technique without mucosectomy, with a loop ileostomy. In the last 18 patients the loop ileostomy was omitted (group B2). A comparison between group A and B and between group B1 and B2 was made concerning anaesthesia time, hospital stay, blood transfusions, postoperative complications and pouch function at 2 and 12 months. It was found that the stapling technique (group B) reduced anaesthesia time considerably and reduced the need of blood transfusions. Postoperatively thromboembolic episodes and signs of adrenal insufficiency were seen only in the handsewn group, while postoperative febrile conditions were more common in the stapled groups. Ileo-anal dehiscence occurred in two patients without loop ileostomy. Treatment by establishment of a loop ileostomy, local irrigation and administration of antibiotics were successful, the anastomoses healed within 2 weeks and there was no further complications before or after loop closure. Omitting the loop ileostomy saved the patient a further operation and reduces hospital stay and sick leave. After two months of pouch function, patients with handsewn pouches had a lower number of bowel movements (5.5/24 h and 0.8 during the night) than patients with stapled pouches (8.0/24 h and 1.9 during the night). At 12 months, however, the difference between the groups of patients had diminished.(ABSTRACT TRUNCATED AT 250 WORDS)

Norfloxacin treatment of salmonellosis does not shorten the carrier stage.

In a prospective controlled study we evaluated the effect of early norfloxacin treatment on the duration of salmonella carriage after acute salmonellosis. The study was carried out during an outbreak of Salmonella typhimurium infection at a military base. 23 patients received norfloxacin 400 mg twice daily for 7 days while 29 patients served as untreated controls. A patient was considered to have ceased being a carrier on the date of the first of 3 negative consecutive cultures. Four weeks after diagnosis 30% of the treated patients and 31% in the control group were still carriers. The corresponding figures after 8 and 12 weeks were 17 and 3% and 4 and 0%, respectively. Thus, one week of norfloxacin treatment instituted at an early stage of salmonellosis did not shorten the duration of carriage.