Patient-Reported Outcome After Ostomy Surgery for Chronic Constipation.

PURPOSE: The purpose of this study was to describe experiences of and evaluate psychosocial and health-related quality of life of individuals undergoing ostomy surgery for severe, chronic constipation. METHODS: A search of the local ostomy archive and the electronic hospital episode statistics database was performed in a large tertiary referral center. Study outcomes were evaluated retrospectively using clinical notes and prospectively via administration of the City of Hope Ostomy Quality of Life questionnaire, Medical Outcomes Study Short Form-36, Hospital Anxiety and Depression tool, and a specially designed ostomy-specific questionnaire. Questionnaires were mailed and returned via post. RESULTS: Twenty-four patients, with a median age of 44 years (interquartile range [IQR] = 31-56), who underwent ileostomy (n = 20) and colostomy (n = 4) over a 13-year period participated in the study. The vast majority of respondents (91%; n = 22) were female. Ten (41%) underwent laparoscopic surgery, 13 (54%) underwent open procedures, and 1 was converted from laparoscopic to open surgery. The mean length of stay (5.5 days vs 5.4 days) and the rate of complication did not differ between the 2 approaches. Fourteen patients (13 females, median age = 47.5 years; IQR = 23-70 years) responded to the postal questionnaires (58.3%). Adverse effects on health-related quality of life in the physical and social well-being domains were reported, and a further 86% of respondents reported psychological morbidity related to their ostomy. However, more than 70% were satisfied (median follow-up = 17 months; IQR = 0.16-8 years) with their quality of life despite a 20% reoperation rate. CONCLUSIONS: An ostomy is a justified last-resort treatment option in selected individuals with severe, chronic constipation. Patients should be warned of the negative effects on health-related quality of life and the risk of complications. We advocate using an algorithm presented in this article.

Factors Associated With Efficacy of Nurse-led Bowel Training of Patients With Chronic Constipation.

BACKGROUND & AIMS: It is not clear whether nurse-led bowel training (NBT), an individually tailored biofeedback strategy designed to improve the physiological process of defecation by operant conditioning and trial and error learning, is effective for patients with chronic constipation. We assessed the ability of NBT to reduce symptoms and increase quality of life in patients with constipation at a large tertiary medical center. METHODS: We performed a retrospective analysis of data from 347 patients (median age, 50 years) who underwent a median 3 sessions of NBT for chronic constipation from January 2011 through December 2013 at St Marks Hospital in the United Kingdom. The NBT comprised a combination of sensory retraining, pelvic floor conditioning, and advice on diet and toileting behavior. Data on patient demographics (age, sex, type of constipation) were collected alongside their assessments of constipation, which were based on Patient Assessment of Constipation Quality of Life (PAC-QoL) and patient satisfaction scores. We performed binary logistic regression analysis. Each variable was tested first at the univariate level; those with significance (P < .10) were included in a multivariate model. RESULTS: At the end of NBT, 62.5% of the patients (217/347) reported reduced symptoms, and 40.2% of the patients (41/102) reported a reduction of at least 1 point on the PAC-QoL score. The mean PAC-QoL scores before and after NBT were 2.42 and 1.41, respectively (P = .001). Multivariate analysis demonstrated that increasing age (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.02-2.87; P = .042), greater number of sessions (OR, 4.14; 95% CI, 2.09-8.20; P < .001), and non-irrigation (OR, 4.39; 95% CI, 1.89-10.19; P = .001) were independent predictors of patient satisfaction. CONCLUSIONS: Data collected immediately after patients with chronic constipation received NBT indicate that it is an effective treatment for most patients. Older patients with dyssynergic defecation benefit most from at least 4 sessions.

Indications and outcome of pelvic exenteration for locally advanced primary and recurrent rectal cancer.

OBJECTIVE: The outcome of pelvic exenteration was compared in patients with locally advanced primary (LAP) cancer and recurrent rectal cancer (RRC). BACKGROUND: There are few reports comparing the results of pelvic exenteration for primary advanced rectal cancer and RRC. METHODS: Consecutive patients undergoing pelvic exenteration between 2006 and 2011 were identified from a prospectively maintained database. The main endpoints were 3-year disease-free survival (DFS) and local recurrence-free survival (LRFS). RESULTS: Of 100 exenterative operations, 55 were for LAP cancer and 45 for RRC. Exenteration of 1 pelvic compartment was required in 30 cases, 2 compartments in 49 cases, and 3 of 4 compartments in 21 cases. R0, R1, and R2 resections were achieved in 78, 15, and 7 cases, respectively. R0 rates were significantly higher in LAP cancer than in RRC (91% vs 62%, P = 0.001). Three-year DFS for R0, R1, and R2 resections was 67%, 49%, and 0%, respectively (P < 0.001). For R0 resections only, DFS in LAP cancer was 76% and 57% in RRC (P = 0.212). On multivariate analysis, a positive resection margin (hazard ratio, 4.04; P < 0.001) and positive lymph node staging (hazard ratio, 2.43; P = 0.022) were significant predictors of reduced DFS. Three-year LRFS for R0 resection was 86% for LAP cancer and 84% for RRC (P = 0.817). On multivariate analysis, only a positive resection margin was a significant predictor of reduced LRFS (hazard ratio, 5.48; P = 0.002). CONCLUSIONS: Resection margin status is more important than primary or recurrent cancer in predicting long-term outcome.

Mucosectomy with handsewn anastomosis reduces the risk of adenoma formation in the anorectal segment after restorative proctocolectomy for familial adenomatous polyposis.

OBJECTIVE: The study compared the risk of adenoma or carcinoma formation in the anorectal segment after either mucosectomy with manual anastomosis or stapled ileoanal anastomosis (IAA) following restorative proctocolectomy (RPC) for familial adenomatous polyposis (FAP). BACKGROUND: Few data exist on the risk of adenoma formation after either technique in FAP. METHODS: All endoscopy and histology reports for patients having RPC for FAP attending for annual pouchoscopy from 1978 to 2007 were reviewed. The incidence, timing, and histological characteristics of adenoma or carcinoma formation were recorded. RESULTS: Of the 206 patients, 140 attended for endoscopic follow-up for a median of 10.3 years after RPC. Fifty-two patients developed neoplastic transformation in the anorectal segment, with a cumulative risk at 10 years of 22.6% after mucosectomy with manual anastomosis and 51.1% after stapled IAA (P < 0.001). The median time to first adenoma was longer after mucosectomy with handsewn anastomosis than after stapled IAA (10.1 vs 6.5 years, P < 0.001). On multivariate analysis, stapled IAA (hazard ratio= 3.45, 95% confidence interval = 1.01­4.98) and age at RPC older than 40 years (hazard ratio = 2.20, 95% confidence interval = 1.01­4.89) were significantly associated with increased risk of adenoma formation. Nine patients developed a large (>10 mm) adenoma. One patient (handsewn ileoanal anastomosis) developed adenocarcinoma in the anorectal mucosa at 13 years and required pouch excision. CONCLUSIONS: Adenoma formation in the anorectal mucosa after RPC for FAP is common but carcinoma is rare. The risk is lower after mucosectomy with handsewn anastomosis than after stapled IAA. Regular endoscopic surveillance after either technique is mandatory.

Extended lymphadenectomy versus conventional surgery for rectal cancer: a meta-analysis.

BACKGROUND: Lateral pelvic lymph-node metastases occur in 10-25% of patients with rectal cancer, and are associated with higher local recurrence and reduced survival rates. A meta-analysis was undertaken to assess the value of extended lateral pelvic lymphadenectomy in the operative management of rectal cancer. METHODS: We searched Medline, Embase, Ovid, Cochrane Library, and Google Scholar for studies published between 1965 and 2009 that compared extended lymphadenectomy (EL) with standard rectal resection. 20 studies, which included 5502 patients from one randomised, three prospective non-randomised, and 14 retrospective case-control studies published between 1984 and 2009, met our search criteria and were assessed. 2577 patients underwent EL and 2925 underwent non-EL for rectal cancer. Random and fixed-effects meta-analytical models were used where indicated, and between-study heterogeneity was assessed. End-points evaluated included peri-operative outcomes, 5-year survival and recurrence rates. FINDINGS: Operating time was significantly longer in the EL group by 76.7 min (95% CI 18.77-134.68; p=0.0096). Intra-operative blood loss was greater in the EL group by 536.5 mL (95% CI 353.7-719.2; p<0.0001). Peri-operative mortality (OR 0.81, 95% CI 0.34-1.93; p=0.63) and morbidity (OR 1.45, 95% CI 0.89-2.35; p=0.13) were similar between the two groups. Data from individual studies showed that male sexual dysfunction and urinary dysfunction (three studies: OR 3.70, 95% CI 1.66-8.23; p=0.0012) were more prevalent in the EL group. There were no significant differences in 5-year survival (hazard ratio [HR] 1.09, 95% CI 0.78-1.50; p=0.62), 5-year disease-free survival (HR 1.23, 95% CI 0.75-2.03, p=0.41), and local (OR 0.83, 95% CI 0.61-1.13; p=0.23) or distant recurrence (OR 0.93, 95% CI 0.72-1.21; p=0.60). INTERPRETATION: Extended lymphadenectomy does not seem to confer a significant overall cancer-specific advantage, but does seem to be associated with increased urinary and sexual dysfunction.

Fecal coliform testing to identify effective antibiotic therapies for patients with antibiotic-resistant pouchitis.

BACKGROUND & AIMS: Empiric antibiotic therapy (eg, a combination of ciprofloxacin and metronidazole) is effective in treating the majority of patients with inflammation of the ileal reservoir (pouchitis). Unfortunately, up to 20% of patients develop refractory or rapidly relapsing disease. We developed a fecal sensitivity analysis to determine which antibiotics are most likely to be effective in patients who do not respond to empiric antibiotic therapy or have relapsed after long-term therapy. METHODS: Fecal samples from 15 patients with active pouchitis (pouch disease activity index [PDAI], > or =7) who failed standard antibiotic treatment were inoculated onto Iso-sensitest agar. Antibiotic testing discs were added, incubated, and sensitivity patterns were recorded. Patients then were treated with antibiotics based on predicted sensitivity; PDAI scores were assessed 4 weeks later. Thirteen patients enrolled in the study had failed to enter remission after treatment with ciprofloxacin and metronidazole and 2 patients had relapsed after maintenance treatment with ciprofloxacin. RESULTS: Antibiotic coliform sensitivity testing showed ciprofloxacin resistance in all samples, co-amoxiclav resistance in 4 samples, trimethoprim resistance in 11 samples, and cefixime resistance in 8 samples. All 15 patients were treated with an antibiotic to which their fecal coliforms were sensitive; 12 (80%) achieved clinical remission (PDAI score, 0). CONCLUSIONS: Fecal coliform sensitivity analysis can identify effective antibiotic therapies for patients with antibiotic-resistant pouchitis. This targeted antibiotic approach is recommended in all patients who fail to respond to empiric antibiotic treatment or relapse after long-term antibiotic therapy.

Diagnostic precision of carcinoembryonic antigen in the detection of recurrence of colorectal cancer.

INTRODUCTION: The aim of the study was to evaluate the diagnostic precision of serum carcinoembryonic antigen (CEA) in the detection of local or distant recurrence following resectional surgery for colon and rectal cancer. METHODS: Quantitative meta-analysis was performed on 20 studies, comparing serum CEA with radiological imaging and/or pathology in detecting colorectal cancer (CRC) recurrence in 4285 patients. The cut-off for a 'positive' CEA ranged from 3 to 15 ng/ml between the various studies. Sensitivity, specificity and diagnostic odds ratio (DOR) were calculated for each study. Summary receiver operating characteristic curves (SROC) and sub-group analysis were undertaken. RESULTS: The overall sensitivity and specificity of CEA for detecting CRC recurrence was 0.64 (95% CI: 0.61-0.67) and 0.90 (95% CI: 0.89-0.91), respectively. The area under the SROC curve was 0.75 (SE=0.04) and the diagnostic odds ratio was 18.44 (95% CI: 11.94-28.49). A CEA cut-off of 5 ng/ml yielded a higher diagnostic odds ratio than a cut-off of 3 ng/ml (15.5 vs. 11.1). Using meta-regression analysis the optimum CEA cut-off point for the best combination of sensitivity and specificity was 2.2 ng/ml. On sub-group analysis high quality studies, and those involving > or =100 patients yielded a marginal improvement in the sensitivity and specificity with minimal change to the SROC. CONCLUSION: Serum CEA is a test with high specificity but insufficient sensitivity for detecting CRC recurrence in isolation. A cut-off of 2.2 ng/ml may provide an ideal balance of sensitivity and specificity. It may be useful as a first-line surveillance investigation in patients during surgical follow-up based on serial CEA measurements using temporal trends in conjunction with clinical, radiological and/or histological confirmation.

Incidence and short-term implications of prepouch ileitis following restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis.

PURPOSE: Pouchitis following restorative proctocolectomy is common. Inflammation proximal to the pouch, prepouch ileitis (PPI) has recently been described. Its incidence and implications are unknown. The aim of this study was to identify the incidence of PPI at pouchoscopy and correlate this with symptoms, diagnosis, and outcome. METHODS: The authors searched the endoscopy database at our institution for the terms "pouchitis" and "ileitis" and reviewed hospital records. RESULTS: A total of 1448 pouchoscopies were performed on 742 patients. PPI was diagnosed in 34 (5.7 percent) patients with ulcerative colitis/indeterminate colitis and 1 (0.6 percent) with polyposis. All of the patients had concurrent pouch inflammation, and in this group the incidence was 13 percent. The median length of the PPI was 10 cm. Asymptomatic patients totaled 26 percent. At follow-up (median, 12 months) no patient was reclassified to Crohn's disease, and no patients required an ileostomy for poor function. CONCLUSIONS: The incidence of PPI in patients with ulcerative colitis/indeterminate colitis is 5.7 percent, and it occurs in 13 percent of patients with pouch inflammation. All of the patients had associated pouch inflammation; however, not all of the patients were symptomatic. Our results demonstrate that PPI is common in patients with pouchitis; it does not imply missed Crohn's disease or predict an increased rate of pouch failure, at least in the short term.

Is rectal washout effective for preventing localized recurrence after anterior resection for rectal cancer?

PURPOSE: The present study evaluated the effect of rectal washout in reducing local recurrence after resection for rectal cancer. METHODS: A literature search was performed on studies published since 1989 that compared rectal washout to no washout for rectal cancer resection. Primary end point was local cancer recurrence. Random-effect meta-analysis was used and subgroup analysis was performed. RESULTS: Five studies matched the selection criteria, and reported on 176 patients who underwent rectal washout and 256 who did not undergo washout. Different washout solutions were used in every study, and total mesorectal excision was not universally applied. Overall local recurrence rate was 8 percent (33/432). Local recurrence rate for rectal washout patients was 4.8 percent compared with 10.2 percent for patients who did not undergo rectal washout, a difference that was not statistically significant (odds ratio = 0.64; 95 percent confidence interval = 0.2-2.04). When only studies using total mesorectal excision were considered, there was no significant difference between the two groups (odds ratio = 1.21; 95 percent confidence interval = 0.37-3.92). CONCLUSIONS: Although no definitive conclusions may be drawn because of the nonrandomized nature of the included studies, rectal washout is relatively risk-free and adds little to the operative time. This may be performed until a randomized, controlled trial is undertaken to resolve this contentious issue.

Sacral nerve stimulation for fecal incontinence related to obstetric anal sphincter damage.

PURPOSE: Sphincter repair is the standard treatment for fecal incontinence secondary to obstetric external anal sphincter damage; however, the results of this treatment deteriorate over time. Sacral nerve stimulation has become an established therapy for fecal incontinence in patients with intact sphincter muscles. This study investigated its efficacy as a treatment for patients with obstetric-related incontinence. METHODS: Fecally incontinent patients with external sphincter defects who would normally have undergone overlapping sphincter repair as a primary or repeat procedure were included. Eight consecutive women (median age, 46 (range, 35-67) years) completed temporary screening; all eventually had permanent implantation. RESULTS: Six of eight patients had improved continence at median follow-up of 26.5 (range, 6-40) months. Fecal incontinent episodes improved from 5.5 (range, 4.5-18) to 1.5 (range, 0-5.5) episodes per week (P = 0.0078). Urgency improved in five patients, with ability to defer defecation improving from a median of <1 (range, 0-5) minute to 1 to 5 (range, 1 to >15) minutes (P = 0.031, all 8 patients). There was no change in anal manometry or rectal sensation. There was significant improvement in lifestyle, coping/behavior, depression/self-perception, and embarrassment as measured by the American Society of Colon and Rectal Surgery fecal incontinence quality of life score. CONCLUSIONS: Sacral nerve stimulation is potentially a safe and effective minimally invasive treatment for fecal incontinence in patients with de novo external anal sphincter defects or defects after unsuccessful previous external anal sphincter repair, although numbers remain small.

Sacral spinal nerve stimulation for faecal incontinence: multicentre study.

BACKGROUND: In patients with faecal incontinence in whom conservative treatment fails, options are limited for those with a functionally deficient but morphologically intact sphincter. We investigated the effect of sacral nerve stimulation on continence and quality of life. METHODS: In this multicentre prospective trial, 37 patients underwent a test stimulation period, followed by implantation of a neurostimulator for chronic stimulation in 34. Effect on continence was assessed by daily bowel-habit diaries over a 3-week period and on quality of life by the disease-specific American Society of Colon and Rectal Surgeons (ASCRS) questionnaire and the standard short form health survey questionnaire (SF-36). Every patient served as his or her own control. FINDINGS: Frequency of incontinent episodes per week fell (mean 16.4 vs 3.1 and 2.0 at 12 and 24 months; p<0.0001) for both urge and passive incontinence during median follow-up of 23.9 months. Mean number of days per week with incontinent episodes also declined (4.5 vs 1.4 and 1.2 at 12 and 24 months, p<0.0001), as did staining (5.6 vs 2.4 at 12 months; p<0.0001) and pad use (5.9 vs 3.7 at 12 months; p<0.0001). Ability to postpone defecation was enhanced (at 12 months, p<0.0001), and ability to completely empty the bowel was slightly raised during follow-up (at 12 months, p=0.4122). Quality of life improved in all four ASCRS scales (p<0.0001) and in seven of eight SF-36 scales, though only social functioning was significantly improved (p=0.0002). INTERPRETATION: Sacral nerve stimulation greatly improves continence and quality of life in selected patients with morphologically intact or repaired sphincter complex offering a treatment for patients in whom treatment options are limited.

Nationwide linkage analysis in Scotland-Has mortality following hospital admission for Crohn's disease changed in the early 21st century?

BACKGROUND: National Scottish data were used to compare 3-year mortality in patients hospitalized for Crohn's disease (CD) between 1998-2000 and 2007-2009. METHODS: The linked Scottish Morbidity Records database was used to identify patients admitted with CD during two periods: Period 1 (1998-2000) and Period 2 (2007-2009). 3-year mortality and standardized mortality ratio (SMR) were determined and multivariable logistic regression analysis of associated factors was performed. Mortality was determined following four admission types: surgery-elective, surgery-emergency, medical-elective and medical-emergency. 3-year mortality was compared between study periods using age-standardized rates. RESULTS: The number of patients per 100,000 population hospitalized with CD per year was unchanged (15.7 [Period 1]; 14.4 [Period 2]). Overall crude and adjusted 3-year mortality rates were also unchanged (crude mortality 9.0%-9.1%, adjusted mortality odds ratio [OR]=0.87, 95% confidence interval [CI] 0.65-1.17; p=0.36). The adjusted 3-year mortality increased following elective surgery (Period 1: 1/303 [0.3%]; Period 2: 9/261 [3.4%]); OR=13.5 [CI 1.66-109.99]) and decreased following emergency medical admission (Period 1: 99/779 [12.7%]; Period 2:86/802 [10.7%]; OR=0.68 [CI 0.47-0.97]). Directly age-standardized mortality rates were similar (Period 1:338/10,000 person years [CI 282-394]; Period 2:333/10,000 person years [CI 276-390], p=0.2). On multivariable regression, age, deprivation status, comorbidity and the length of hospital stay were associated with mortality in both periods. High 3-year mortality was observed during both periods in patients between 50 and 64years (Period 1: 33/298 [11.1%, SMR=4.8 [CI 3.44-6.63], Period 2: 33/296 [11.1%, SMR=5.9 [4.14-8.22]) and over 65years(Period 1: 94/275 [34.2%, SMR=2.78 [CI 2.42-3.62], Period 2: 78/251 [31.1%, SMR=3.31 [2.64-4.11]). CONCLUSION: Nationwide linkage data demonstrate that overall 3-year mortality after hospitalization for CD is high, especially in patients over 50years, and has not altered between the time periods 1998-2000 and 2007-2009.

Fistula in ano: an overview.

Perianal fistula is a very unpleasant condition. It is also quite difficult to be solved without recurrence or with complete preservation of sphincter function. This paper summarizes the etiology, classification of fistulas along with the long-term surgical experiences in the approach and the treatment of this condition.

Variation in reoperation after colorectal surgery in England as an indicator of surgical performance: retrospective analysis of Hospital Episode Statistics.

OBJECTIVE: To describe national reoperation rates after elective and emergency colorectal resection and to assess the feasibility of using reoperation as a quality indicator derived from routinely collected data in England. DESIGN: Retrospective observational study of Hospital Episode Statistics (HES) data. SETTING: HES dataset, an administrative dataset covering the entire English National Health Service. PARTICIPANTS: All patients undergoing a primary colorectal resection in England between 2000 and 2008. MAIN OUTCOME MEASURES: Reoperation after colorectal resection, defined as any reoperation for an intra-abdominal procedure or wound complication within 28 days of surgery on the index or subsequent admission to hospital. RESULTS: The national reoperation rate was 6.5% (15,986/246,469). A large degree of variation was identified among institutions and surgeons. Even among institutions and surgical teams with high caseloads, threefold and fivefold differences in reoperation rates were observed between the highest and lowest performing trusts and surgeons. Of the NHS trusts studied, 14.1% (22/156) had adjusted reoperation rates above the upper 99.8% control limit. Factors independently associated with higher risk of reoperation were diagnosis of inflammatory bowel disease (odds ratio 1.33 (95% CI 1.24 to 1.42), P<0.001), presence of multiple comorbidity (odds ratio 1.34 (1.29 to 1.39), P<0.001), social deprivation (1.14 (1.08 to 1.20) for most deprived, P<0.001), male sex (1.33 (1.29 to 1.38), P<0.001), rectal resection (1.63 (1.56 to 1.71), P<0.001), laparoscopic surgery (1.11 (1.03 to 1.20), P = 0.006), and emergency admission (1.21 (1.17 to 1.26), P<0.001). CONCLUSIONS: There is large variation in reoperation after colorectal surgery between hospitals and surgeons in England. If data accuracy can be assured, reoperation may allow performance to be checked against national standards from current routinely collected data, alongside other indicators such as mortality.

To divert or not to divert: A retrospective analysis of variables that influence ileostomy omission in ileal pouch surgery.

HYPOTHESIS: A model could be developed to identify patients who can safely undergo restorative proctocolectomy (RPC) without proximal diversion. DESIGN: Logistic regression analysis was used to identify independent factors favoring omission of ileostomy at the time of RPC. A propensity nomogram was developed and validated using measures of calibration, discrimination, and subgroup analysis. SETTING: Two tertiary referral centers. PATIENTS: A total of 4013 patients undergoing RPC between January 1977 and December 2005 were included in the study sample. MAIN OUTCOME MEASURE: The decision to omit loop ileostomy at the time of RPC. RESULTS: After study group exclusions, proximal diversion was performed in 3196 of 3733 patients (85.6%) undergoing RPC; 45.4% of 3733 patients were women. The mean (SD) age at surgery was 37.4 (12.8) years. Ulcerative colitis was the indication for RPC in 2304 patients (61.7%) and familial adenomatous polyposis in 364 patients (9.8%), and a J pouch was performed in 2657 patients (71.2%). The following were found to be associated with ileostomy omission: stapled anastomosis (odds ratio [OR], 6.4), no preoperative corticosteroid use (OR, 3.2), familial adenomatous polyposis diagnosis (OR, 2.6), cancer diagnosis (OR, 3.4), female sex (OR, 1.6), and age at surgery younger than 26 years (OR, 2.1) (P < .01 for all). The model discriminated well (area under the receiver operating characteristic curve, 74.9%), with no significant differences between observed and expected outcomes (P = .49). Omission of proximal diversion demonstrated no significant effect on postoperative adverse events, although it was associated with a 2-day increase in the median length of hospital stay (P < .01). CONCLUSION: Incorporation of a 5-point nomogram in the preoperative assessment of patients undergoing RPC may aid clinicians in identifying a select group of patients who may be candidates for ileostomy omission during RPC.

Osteoporosis in patients over 50 years of age following restorative proctocolectomy for ulcerative colitis: is DXA screening warranted?

BACKGROUND: Ulcerative colitis (UC) and increasing age are associated with an increased risk of osteoporosis. Screening of postmenopausal women and men older than 50 years with ulcerative colitis for osteoporosis is recommended. The prevalence of osteoporosis in restorative proctocolectomy (RPC) patients more than 50 years old is not known. METHODS: Fifty-three consecutive patients older than age 50 who had undergone RPC for UC underwent a bone density scan (DXA). Sex, smoking status, age at diagnosis of UC, duration of UC, age at RPC, years since RPC, age at DXA, and pouch histological inflammatory score were recorded. The Kruskal-Wallis test and Spearman's correlation coefficient were used to analyze the data. RESULTS: Fifty-three patients were studied; their median age was 58 years, and the median age at RPC was 45. The prevalence of osteopenia and osteoporosis was 43.4% and 13.2%, respectively. Age at RPC was negatively correlated with bone density (P = 0.041, r = 0.281), and there was a negative correlation approaching significance with age at the time of DXA (P = 0.071, r = -0.250). No other factor studied correlated with bone density. CONCLUSIONS: The prevalence of osteoporosis and osteopenia found in this study is similar to that reported for UC patients who have not undergone RPC. Patients having RPC should be screened in line with current UC guidelines, targeting those older than 50 years.

Guide to endoscopy of the ileo-anal pouch following restorative proctocolectomy with ileal pouch-anal anastomosis; indications, technique, and management of common findings.

Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis is the surgical procedure of choice for patients with ulcerative colitis (UC). It is also performed in selected patients with familial adenomatous polyposis (FAP). A significant proportion of patients will develop pouch dysfunction. Flexible pouchoscopy is the most important initial investigation in patients with dysfunction. It is also important in UC and FAP surveillance. The aim is to provide gastroenterologists with a clear understanding of the technique, indications, and diagnostic pitfalls when investigating RPC patients with flexible pouchoscopy. Flexible pouchoscopy for the investigation of RPC patients with pouch dysfunction has a high diagnostic yield, with most causes of pouch dysfunction identifiable during this procedure. The risk of developing dysplasia following RPC is low. Surveillance pouchoscopy is only recommended in those with FAP, those with a previous history of dysplasia or carcinoma, primary sclerosing cholangitis, those with a retained rectal cuff, and those with Type C histological changes. Flexible pouchoscopy is a useful first-line investigation in patients with pouch dysfunction. It can be performed without sedation and has a high diagnostic yield; it is also important as part of surveillance in FAP and selected UC patients.