Prevalence and management of prolapse of the ileoanal pouch.

PURPOSE: Known late complications of ileal pouch-anal anastomoses include chronic pouchitis, poor pouch function, or stricture. These may jeopardize the pouch and may require pouch salvage procedures. Prolapse of the ileoanal pouch is a little-known complication infrequently noted in the literature. The objective of this study was to determine the prevalence of this problem and identify approaches used to correct it and salvage the pouch. METHODS: The literature was reviewed for publications describing the diagnosis and treatment of patients with ileoanal pouch prolapse. A survey inquiring about experience with ileoanal pouch prolapse was sent to all North American members and fellows of The American Society of Colon and Rectal Surgeons. The survey assessed the number of years that the respondent had been performing ileal pouch-anal anastomoses and the number and type of pouches constructed. The respondents indicated the prevalence of patients with ileoanal pouch prolapse in their practices and length of time from pouch creation to onset of prolapse. They also were asked to indicate presenting symptoms, need for and method of surgical repair, and outcome. RESULTS: Two hundred and sixty-nine responses were received (response rate, 19.5 percent). Thirty-five respondents indicated that they had assisted in the care of a total of 83 patients with prolapse of the ileoanal pouch. Prolapse symptoms included external prolapse of tissue, sense of obstructed defecation, seepage, and pain. Patients with pouch prolapse most commonly presented within two years of pouch construction. Fifty-two patients required surgery and were managed by a combination of transanal repair, abdominal pouchpexy, and transabdominal revision or removal. The ileoanal pouch was salvaged in all but one case. CONCLUSIONS: Although the incidence of pouch prolapse is relatively low in this survey, the number of cases reported far exceeds the previous known experience. The possibility of this clinical entity should be considered in the differential diagnosis of ileoanal pouch dysfunction. Such recognition should lead to correction of prolapse and pouch salvage in the great majority of patients.

Use of a critical pathway for colon resections.

Tremendous variation in patient care exists, both among medical centers and among individual surgeons, in the field of colon and rectal surgery. Clinical or critical pathways based on "best demonstrated practices" from the medical literature have led to improved outcomes for many disease entities. The objective of this study was to develop a pathway for elective colon and rectal resections, and then determine whether this led to any improvement in measurable outcomes. A critical pathway was developed for the care of patients undergoing elective colon and rectal surgery, by reviewing best demonstrated practices in the literature and then developing standardized order sheets, nursing flow sheets, and patient educational material. A patient satisfaction survey was also included in the evaluation process. After being informed of the positive results from the pilot study, surgeons were encouraged to use the critical pathway order sheets, patient information sheets, and flow sheets for their patients undergoing elective abdominal colon or rectal surgery. Between January 1995 and October 1998, the critical pathway was used for 263 patients, whereas for 122 patients this pathway was not used. For those patients in the critical pathway group, the hospital length of stay was shorter (5.5 vs. 8.2 days, including the day of surgery, P = 0.001), the time until a regular diet was tolerated was shorter (3.5 vs. 4.4 days, P = 0.001), the percentage of patients discharged home was greater (90% vs. 82%, P = 0.038), and the average hospital charges were less (12,672 dollars vs. 16,665 dollars, P = 0.001). These advantages did seem to be correlated with efforts at postoperative ambulation, but were independent of the type of postoperative pain control (patient-controlled analgesia vs. epidural analgesia). Patient satisfaction in the subset surveyed was slightly better for those in the critical pathway group than in those for whom the critical pathway was not used. Elective colon and rectal surgery appears to lend itself to uniformity of postoperative order sheets and clinical expectations. Shortened lengths of hospital stay, earlier resumption of a regular diet, and diminished hospital charges were found with the use of this critical pathway, with no diminution of patients' perceptions of satisfaction with the hospital experience.