The role of the defaecating pouchogram in the assessment of evacuation difficulty after restorative proctocolectomy and pouch-anal anastomosis.

AIM: Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) is the most frequently performed operation for intractable ulcerative colitis (UC) and for many patients with familial adenomatous polyposis (FAP). It can be complicated by a functional evacuation difficulty, which is not well understood. We aimed to evaluate the role of defaecating pouchography in an attempt to assess the mechanism of evacuation difficulty in pouch patients. METHOD: All RPC patients who had had a defaecating pouchogram for evacuation difficulty at one hospital between 2006 and 2014 were retrospectively reviewed. The findings and features were correlated with the symptoms. Demographic, clinical and radiological variables were analysed. RESULTS: Eighty-seven [55 (63%) female] patients aged 47.6 ± 12.5 years (mean standard ± SD) were identified. Thirty-five had a mechanical outlet obstruction and 52 had no identified mechanical cause to explain the evacuation difficulty. The mean age of these 52 [33 (63%) female] patients was 48.2 ± 13 years. Of these 52 patients, significantly more used anti-diarrhoeal medication (P = 0.029), complained of a high frequency of defaecation (P = 0.005), experienced a longer time to the initiation of defaecation (P = 0.049) and underwent pouchoscopy (P = 0.003). Biofeedback appeared to improve the symptoms in 7 of 16 patients with a nonmechanical defaecatory difficulty. The most common findings on defaecating pouchography included residual barium of more than 33% after an attempted evacuation (46%, n = 24), slow evacuation (35%, n = 18) and mucosal irregularity (33%, n = 17). Correlation between radiological features and symptoms showed a statistically significant relationship between straining, anal pain, incontinence and urgency with patterns of anismus or pelvic floor descent or weakness seen on the defaecating pouchogram. Symptoms of incomplete evacuation, difficulty in the initiation of defaecation, high defaecatory frequency and abdominal pain were not correlated with the radiological features of the pouchogram. CONCLUSION: Defaecating pouchography may be useful for identifying anismus and pelvic floor disorders in pouch patients who have symptoms of straining, anal pain or incontinence. In patients with a high frequency of defaecation and abdominal pain it does not provide clinically meaningful information. Patients who complain of straining, incontinence, anal pain or urgency and have anismus or pelvic floor disorders may benefit from behavioural therapy.

Elective colonic surgery for cancer in the elderly: an investigation into postoperative mortality in English NHS hospitals between 1996 and 2007.

BACKGROUND: This study was primarily aimed to quantify perioperative mortality risk in elderly patients undergoing elective colonic resectional surgery. In addition, the safety of minimally invasive colonic surgery in this patient group was evaluated. METHODS: All patients aged > 75 undergoing elective colonic resection for colorectal malignancy between 1996 and 2007 in English NHS hospitals were included from the Hospital Episode Statistics (HES) dataset. RESULTS: Between the study dates, 28,746 patients > 75 years underwent elective colonic resection. The national annual number of colonic excisions carried out amongst elderly patients increased from 2188 patients in 1996/7 to 3240 patients in 2006/7. Following adjustment for gender, comorbidity and surgical approach, advancing age was an independent predictor for 30-day mortality (OR 2.47 for patients aged 85-89 vs 75-79, P < 0.001). Use of laparoscopy was a significant predictor of reduced perioperative mortality (OR 0.56, P = 0.003) once adjusted for advancing age, gender and comorbidity. Comparison of 30-day and 1-year postoperative mortality following elective colonic resection in patients aged 90 revealed a large excess of patients dying outside of the immediate perioperative period (10.1% and 26.2% for proximal cancers, respectively; 12.9% and 36.1% for distal colonic resections, respectively). CONCLUSIONS: Advancing age is an independent risk factor for postoperative death in elderly patients undergoing elective colonic resection for cancer. The risk of death in the elderly is extremely high and surgical decision-making should incorporate the mortality risk that occurs outside the immediate perioperative period. In this national series, patients selected for a laparoscopic procedure were at lower risk of perioperative death than those undergoing the conventional approach.

Extended spectrum beta-lactamase-producing bacteria and Clostridium difficile in patients with pouchitis.

BACKGROUND: Treatment with fluoroquinolones is associated with the development of Clostridium difficile and extended spectrum beta-lactamase-producing bacteria (ESBL). Clostridium difficile and ESBL are resistant to many antibiotics and each may cause pouchitis after restorative proctocolectomy (RPC) refractory to empirical antibiotic therapy. AIM: To assess the prevalence and establish risk factors for the development of ESBL and Clostridium difficile toxins (CDT) in RPC patients with recurrent or refractory pouchitis under follow-up at our institution over a 1-year period. METHOD: An enzyme-linked immunosorbent assay was used to detect CDT and a culture technique was used to identity ESBL in faecal samples. All patients had previously received fluoroquinolone treatment. RESULTS: Forty-eight patients (35 (74%) men; median age 42 years) underwent testing at a median interval from RPC of 8 (range 1-25) years. No patient had a positive CDT result, but ESBL bacteria were identified in 16 (33%) samples. ESBL positivity was significantly related to prepouch ileitis (P = 0.035) and maintenance antibiotic therapy (P = 0.039). CONCLUSIONS: Extended spectrum beta-lactamase, but not CDT, is a common finding in faecal samples from patients with recurrent or refractory pouchitis. Treatment with maintenance antibiotics and prepouch ileitis are risk factors for developing ESBL-producing bacteria.

An open study of antibiotics for the treatment of pre-pouch ileitis following restorative proctocolectomy with ileal pouch-anal anastomosis.

BACKGROUND: Pre-pouch ileitis is a recently described condition which may occur following restorative proctocolectomy. Its aetiology remains unknown and only one study has reported the effect of treatment. We report a series of fourteen patients treated and followed up with repeat pouchoscopy. AIM: To study the effectiveness of antibiotics for the treatment of pre-pouch ileitis following restorative proctocolectomy with ileal pouch-anal anastomosis. METHODS: Fourteen consecutive patients with symptomatic pre-pouch ileitis were treated with ciprofloxacin 500 mg b.d. and metronidazole 400 mg b.d. for 28 days. All had concurrent pouchitis. Symptomatic, endoscopic and histological assessment was performed before and following treatment using the pouchitis disease activity index (PDAI). Symptomatic remission was defined as a score of 0 in the clinical component of the PDAI. RESULTS: Twelve (86%) patients experienced symptomatic remission. Stool frequency fell from a median of 12 (range 8-20) to 6 (4-17) (P = 0.002). There was a significant reduction in the anatomical length of pre-pouch ileitis with nine (64%) patients having either a resolution or a reduction in length of pre-pouch ileitis from a median of 10 cm (range 3-20 cm) to a median of 1 cm (range 0-10 cm) (P = 0.007). CONCLUSION: Combination antibiotic therapy in this uncontrolled study appears effective in reducing the length of pre-pouch ileitis and in inducing symptomatic remission in most patients whether or not its extent is reduced.