Spatiotemporal analysis of lake chlorophyll-a with combined in situ and satellite data.

We estimated chlorophyll-a (Chl-a) concentration using various combinations of routine sampling, automatic station measurements, and MERIS satellite images. Our study site was the northern part of the large, shallow, mesotrophic Lake Pyhäjärvi located in southwestern Finland. Various combinations of measurements were interpolated spatiotemporally using a data fusion system (DFS) based on an ensemble Kalman filter and smoother algorithms. The estimated concentrations together with corresponding 68% confidence intervals are presented as time series at routine sampling and automated stations, as maps and as mean values over the EU Water Framework Directive monitoring period, to evaluate the efficiency of various monitoring methods. The mean Chl-a calculated with DFS in June-September was 6.5-7.5 µg/l, depending on the observations used as input. At the routine monitoring station where grab samples were used, the average uncertainty (standard deviation, SD) decreased from 2.7 to 1.6 µg/l when EO data were also included in the estimation. At the automatic station, located 0.9 km from the routine monitoring site, the SD was 0.7 µg/l. The SD of spatial mean concentration decreased from 6.7 to 2.9 µg/l when satellite observations were included in June-September, in addition to in situ monitoring data. This demonstrates the high value of the information derived from satellite observations. The conclusion is that the confidence of Chl-a monitoring could be increased by deploying spatially extensive measurements in the form of satellite imaging or transects conducted with flow-through sensors installed on a boat and spatiotemporal interpolation of the multisource data.

Restorative Proctocolectomy in Ulcerative Colitis: Effect of Preoperative Immunomodulatory Therapy on Postoperative Complications and Pouch Failure.

BACKGROUND AND AIMS: Patients with ulcerative colitis are often treated with multiple immunomodulative agents to achieve remission. In refractory disease, the next option is frequently proctocolectomy with ileal pouch-anal anastomosis. No consensus exists as to whether immunomodulatory therapy at the time of ileal pouch surgery leads to any increase in postoperative complications. Our aim was to assess, in ulcerative colitis patients with restorative proctocolectomy, the effect of preoperative anti-tumor necrosis factor therapy and corticosteroids on postoperative complications and pouch failure. MATERIALS AND METHODS: A retrospective medical record review of 445 patients with ulcerative colitis who underwent proctocolectomy with ileal pouch-anal anastomosis in Helsinki University Hospital between January 2005 and June 2016. RESULTS: Anti-tumor necrosis factor agents were not associated with postoperative complications. Only high-dose corticosteroids (prednisolone ⩾20 mg or equivalent) were associated with higher incidence of anastomotic leak (12.6% vs 2.5%, P = 0.002) and wound dehiscence (4.2% vs 0%, P = 0.019), but pouch failure rate was no higher (2.1% vs 0%, P = 0.141) than in patients without corticosteroid treatment. A lower dosage of corticosteroids had no effect on early postoperative complications, but pouch failure rate was increased (4.4% vs 0%, P = 0.015). CONCLUSION: Corticosteroids, but not anti-tumor necrosis factor therapy, were associated with postoperative complications. Preoperative use of corticosteroids may increase pouch failure rate, but the risk is still minor in high-volume centers performing ileal pouch surgery.

Timing of prophylactic colectomy in familial adenomatous polyposis.

AIM: The aim was to evaluate the timing of prophylactic colectomy in patients with familial adenomatous polyposis (FAP) in Finland. METHOD: All Finnish FAP patients were included from the years 1963-2018. Among the 452 FAP patients studied, 252 were called up as relatives of the proband. Of these, 180 underwent prophylactic colectomy. Patient data including mutation characteristics and surgical technique were collected. We assessed the timing of prophylactic colectomy in relation to the time of diagnosis, time of decision for surgery and age. RESULTS: There were 94 (52%) colectomies with ileorectal anastomosis, 79 (44%) proctocolectomies with ileal pouch-anal anastomosis and seven (4%) proctocolectomies with an ileostomy. Median age at diagnosis and at the time of surgery was 20.9 and 25.2 years, respectively. The median time from decision to operate to undergoing surgery was 4 months. There were eight (4%) cancers in the colectomy specimens, but none was found during the annual follow-ups after the first-round endoscopy. After genetic testing became available, the diagnosis was made primarily by either genetic testing in 52 (49%) or endoscopy in 54 (51%) patients at a median age of 17.8 and 19.3 years, respectively. Thirty-eight (21%) patients died during follow-up, 23 (61%) for FAP-related reasons and only six from rectal cancer. The relative survival of 30 years from diagnosis was 84% and 78% in men and women, respectively. CONCLUSIONS: For those who underwent surgery, timing of prophylactic surgery was successful as there were no unexpected colorectal cancers found in colectomy specimens among the screened patients. Two major improvements over the study period have changed the treatment of FAP patients: one is the introduction of the ileal pouch-anal anastomosis procedure and the other is the availability of genetic testing. FAP-related extra-colonic malignancies affect the relative survival of these patients after prophylactic surgery.

Clinical management of 52 consecutive retro-rectal tumours treated at a tertiary referral centre.

AIM: The aim of this single-institution study was to analyse the diagnostic methods, preoperative work-up and outcomes of 52 retro-rectal tumours. METHOD: All patients treated for retro-rectal tumours from 2012 to 2017 were included. RESULTS: Out of 52 patients, 40 (77%) were women. The median age of patients at the time of surgery was 43 (19-76) years, and 30 (58%) were asymptomatic at the time of diagnosis. All tumours were visible on magnetic resonance imaging (MRI) prior to surgery. The sensitivity and specificity for predicting malignancy on preoperative imaging for retro-rectal tumours were 25% and 98%, respectively. Forty-four procedures (85%) were performed using the perineal approach. The median hospital stay was 3 (1-18) days. There was no 30-day postoperative mortality. Eleven (21%) patients developed postoperative complications, mostly surgical site infections. Twenty-nine tumours (56%) were benign tailgut cysts. Four (8%) tumours were malignant and were considered to be removed with a tumour-free resection margin. Local recurrent disease was detected on MRI in 14 (27%) patients at a median of 1.05 (range 0.78-1.77) years after primary surgery. Only the multi-lobular shape of the tumour was found to be an independent risk factor for recurrence (P = 0.030). CONCLUSION: A preoperative MRI is mandatory in order to plan the surgical strategy for retro-rectal tumours. Symptomatic, solid, large tumours should be removed because of the risk of malignancy. Minor cystic lesions with thin walls as well as asymptomatic recurrences of benign tumours are suitable to be followed conservatively.

Morbidity related to diverting ileostomy after restorative proctocolectomy in patients with ulcerative colitis.

AIM: Restorative proctocolectomy with ileal pouch-anal anastomosis is considered by many surgeons to be the standard procedure for surgical management of ulcerative colitis. There is controversy about whether or not a covering ileostomy should be constructed. The aim of this study was to evaluate the outcomes and morbidity for patients with ulcerative colitis who underwent restorative proctocolectomy with or without a diverting ileostomy. METHOD: This is a retrospective study of a consecutive series of 510 patients with ulcerative colitis who were operated on in Helsinki University Hospital between January 2005 and June 2016. A diverting ileostomy was performed in 119 patients (the stoma group) compared with 391 patients with no stoma. RESULTS: Dehydration and intestinal obstruction occurred more often in the stoma group (P < 0.0001). Clinical anastomotic leakage was more common among patients without an ileostomy (6.6% vs 1.7%, P = 0.04). However, the need for re-laparotomy because of any early complication did not differ between the groups (P = 0.58). Within 3 months, 50 patients with ileostomy (42.0%) and 51 patients without (13.0%) were readmitted (P < 0.0001). In total, 35 patients (29.3%) had a complication relating to ileostomy closure and four of them required surgery. There was no difference in the rate of fistulas, pouchitis or pouch failure between the groups. CONCLUSION: Our study shows that a diverting ileostomy is associated with considerable morbidity but it does not seem to prevent later failure of the pouch. We suggest that a diverting ileostomy should only be constructed for high-risk patients.

Oncological outcomes before and after the extralevator abdominoperineal excision era in rectal cancer patients treated with abdominoperineal excision in a single centre, high volume unit.

AIM: The extralevator abdominoperineal excision (ELAPE) has been expected to reduce the risk of positive circumferential resection margins (CRMs) and local recurrence in locally advanced distal rectal cancer. The aim was to determine whether there is any difference in local recurrence rates between patients who were operated on for distal rectal cancer before and after the introduction of ELAPE in our unit. PATIENTS AND METHODS: In all, 206 patients with distal rectal cancer without distant metastases (T1-4N0-2M0) were treated with curative intent. The patients were divided into two cohorts operated in 2000-2007 (A) and 2008-2014 (B). The ELAPE procedure was introduced in 2008. Since then, it has been used in cases of T4 and T3 tumours with threatened margins. In T1-T3 tumours without threatened margins a conventional abdominal perineal excision has been performed. RESULTS: There was no significant difference in overall survival or cancer-specific survival between the two time periods. The local recurrence rate was 15.5% in group A and 6.7% in group B (P = 0.048), although there was no significant difference in the cumulative local recurrence rate. Intra-operative tumour perforation occurred significantly more often during the earlier period when ELAPE was not in use: group A 15/71 (21.1%) vs group B 11/135 (8.1%), P = 0.01. CRM was positive more often in group A (16.4%) vs group B (7.4%), P = 0.054. CONCLUSION: The local recurrence rate, intra-operative tumour perforation and positive CRM rate were significantly lower during the later period when more extensive surgery (ELAPE) was performed for locally advanced T3-T4 rectal cancer with threatened margins.

Oncological results of extended resection for locally advanced rectal cancer: the value of postirradiation MRI in predicting local recurrence.

AIM: The primary purpose of this study was to analyse the overall survival and local recurrence rate after extended resection of locally advanced rectal cancer. The second aim was to determine the ability of the response to radiological irradiation to predict R0 resection. METHOD: A retrospective study was performed of 94 consecutive patients with locally advanced rectal cancer operated on at the Helsinki University Hospital, Helsinki, Finland between 2005 and 2013. Data were collected from patient records. All patients were treated with an en bloc resection. Sixty-two patients received preoperative long-term chemoradiotherapy. RESULTS: The 30-day mortality was 3.2%. Local recurrence occurred in 10 (10.6%) patients. The cumulative 1-, 3- and 5-year overall survival to each year was 89.4%, 68.3% and 51.8%. The most important prognostic factor for both local recurrence (P = 0.006) and survival (P = 0.003) was an R0 resection. A poor or no response seen on posttreatment MRI predicted local recurrence (P = 0.045) and decreased disease-free survival in patients treated curatively (P = 0.052). The histological tumour regression grade was not associated with local recurrence or survival. CONCLUSION: Multivisceral resection offers a 5-year survival of over 50% and local control of advanced rectal cancer in nearly 90% of carefully selected patients.

Comparison of proctocolectomy and ileal pouch-anal anastomosis to colectomy and ileorectal anastomosis in familial adenomatous polyposis.

Prophylactic surgical options for familial adenomatous polyposis (FAP) are either colectomy and ileorectal anastomosis (IRA) or proctocolectomy and ileal pouch-anal anastomosis (IPAA). The aim of this study was to analyse the short-term and long-term outcomes of these two operative techniques. All patients with FAP in Finland have been prospectively recorded in a database since 1963 were retrospectively reviewed in this analysis. Altogether 140 (61%) colectomies with IRA and 88 (39%) proctocolectomies with IPAA have been performed. Complications occurred in 28 (21%) patients after IRA and in 26 (30%) patients after IPAA. There were 15 (11%) severe complications for IRA and 5 (6%) for IPAA. Twenty-one (15%) patients of the IRA group ended up in conventional ileostomy whereas 3 (3.4%) patients of the IPAA group had their ileal reservoir converted to an ileostomy (p = 0.01). Cumulative survival for IRA was lower than for the IPAA (p = 0.03), but if accounting only for operations made after the IPAA era had commenced, there was no significant difference. IPAA was associated with improved long-term survival without an increase in postoperative complications. The risk of death after colectomy and IRA seemed to be predominantly related to the remaining risk of rectal cancer. Therefore, we favour proctocolectomy with IPAA as the prophylactic surgical procedure for FAP with intermediate or severe polyposis.

Risk of cancer and secondary proctectomy after colectomy and ileorectal anastomosis in familial adenomatous polyposis.

PURPOSE: The aim of our retrospective study was to review the outcome of patients undergoing colectomy with ileorectal anastomosis (IRA) due to familial adenomatous polyposis (FAP) in Finland during the last 50 years. METHODS: The cumulative risk of rectal cancer and the rate of anus preservation were analyzed. A total of 140 FAP patients with previous colectomy combined with ileorectal anastomosis were included. Kaplan-Meier analysis was performed to evaluate cumulative risks. RESULTS: Secondary proctectomy was performed for 39 (28 %) of 140 patients. The cumulative risk of secondary proctectomy was 53 % at 30 years after colectomy with IRA. A total of 17 (44 %) secondary proctectomies were performed due to cancer or suspicion of cancer, and another 17 (44 %) secondary proctectomies were performed due to uncontrollable rectal polyposis. During our study, the anus preservation rate in secondary proctectomies was 49 %. The cumulative risk of rectal cancer was 24 % at 30 years after colectomy with IRA. Therefore, the cumulative rectal cancer mortality 30 years after colectomy with IRA was 9 %. CONCLUSIONS: Proctocolectomy and ileal pouch-anal anastomosis (IPAA) should be favored as a primary operation for patients not having technical or medical contraindications for it because colectomy with IRA carried a rectal cancer risk of 13 % with a mortality of 7 % during our study, and because IPAA is likely to succeed better at earlier phase of the disease. Patients with attenuated FAP had no rectal cancer in our study, and they may form a group where IRA should still be the first choice as an exception.

Feasibility of radical cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for pseudomyxoma peritonei of appendiceal origin.

BACKGROUND AND AIMS: We analyzed the feasibility of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with pseudomyxoma peritonei. MATERIAL AND METHODS: A prospective database comprised 90 consecutive patients with demonstrable pseudomyxoma peritonei collected during 48 months. These patients, referred to our unit for consideration for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, received both cytoreductive surgery and hyperthermic intraperitoneal chemotherapy if possible. We evaluated the factors associated with a successful procedure. RESULTS: Hyperthermic intraperitoneal chemotherapy was successfully delivered to 56 of 90 patients (62%) with demonstrable pseudomyxoma peritonei. Tumor morphology of low grade (p = 0.013), age under 65 years (p = 0.004), and serum carcinoembryonic antigen level under 5.0 µg/L (p = 0.003) were associated with successful administration of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Mean peritoneal cancer index was lower (18.9 vs 32.6, p < 0.001) and age was younger (54.3 vs 61.6, p = 0.003) in patients who underwent hyperthermic intraperitoneal chemotherapy than in patients who did not. Four patients had complete cytoreductive surgery alone, and 20 patients underwent palliative debulking, but 10 were ineligible for this operation. CONCLUSIONS: Although the combination of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is currently suggested the standard practice for pseudomyxoma peritonei, not all patients are eligible for this protocol. In this study, hyperthermic intraperitoneal chemotherapy was suitable for 62% of patients with pseudomyxoma peritonei of appendiceal origin.

Duodenal surveillance improves the prognosis after duodenal cancer in familial adenomatous polyposis.

AIM: Duodenal adenomatosis in familial adenomatous polyposis results in a cancer risk that increases with age. Endoscopic surveillance has been recommended, but the effect has not yet been documented. The aim of this study was to present the results of long-term duodenal surveillance and to evaluate the risk of cancer development. METHOD: Follow up of patients in a previous study with gastroduodenoscopy in 1990-2010. Statistical analysis included the χ(2) test, actuarial method and Kaplan-Meier analysis. RESULTS: Among 304 patients, 261 (86%) had more than one endoscopy. The median follow up was 14 (interquartile range, 9-17) years. The cumulative lifetime risk of duodenal adenomatosis was 88% (95% CI, 84-93), and of Spigelman stage IV was 35% (95% CI, 25-45). The Spigelman stage improved in 32 (12%) patients, remained unchanged in 88 (34%) and worsened in 116 (44%). Twenty (7%) patients had duodenal cancer at a median age of 56 (range, 44-82) years. The cumulative cancer incidence was 18% at 75 years of age (95% CI, 8-28) and increased with increasing Spigelman stage at the index endoscopy to 33% in Spigelman stage IV (P < 0.0001). The median overall survival was 6.4 years (95% CI, 1.7 to not estimated): 8 years after a screen-detected cancer vs 0.8 years (95% CI, 0.03-1.7) after a symptomatic cancer (P < 0.0001). The location of the mutation in the APC gene did not influence the risk of developing Spigelman stage IV (P = 0.46) or duodenal cancer (P = 0.83). CONCLUSION: The risk of duodenal cancer in familial adenomatous polyposis is considerable, and regular surveillance and cancer prophylactic surgery result in a significantly improved prognosis.

Risk of cancer in patients with chronic pouchitis after restorative proctocolectomy for ulcerative colitis.

AIM: The aim of this study was to evaluate the consequences of chronic pouchitis after restorative proctocolectomy for ulcerative colitis. METHOD: Forty-two patients with chronic pouchitis underwent pouch endoscopy with biopsies after a median of 8.3 years of postoperative follow up. The pouchitis disease activity index (PDAI) was calculated. Morphological changes were recorded. Immunohistochemical analyses for cyclooxygenase 2 (COX-2), Ki-67 and p53 were performed, as was DNA flow cytometry. Endoscopy was also carried out in 10 patients without pouchitis and in nine healthy subjects. RESULTS: In patients with chronic pouchitis, the PDAI was 6 (standard error of the mean ± 4). Eighteen (43%) patients used continuous medication. The PDAI correlated positively with villous atrophy (P < 0.05). None of the pouch biopsies showed dysplasia. COX-2 immunostaining was detected in 35 (83.3%) patients with chronic pouchitis, in five (50%) without pouchitis, but in none of the normal controls. COX-2 expression correlated with mucosal atrophy (P < 0.01). In 15 (35.7%) of 42 patients with chronic pouchitis, Ki-67 immunostaining was increased, but no increase was observed in either control group (P < 0.002). No p53 immunopositivity was found, and DNA flow cytometry was normal in all pouches. One of the patients developed adenocarcinoma at the anal anastomosis. CONCLUSION: No dysplastic changes were detected during the first decade after surgery. Routine follow up of patients with chronic pouchitis with a hand-sewn anastomosis may not be necessary, although a small risk of cancer seems to remain at the anal anastomosis. The follow up should be focused on at-risk groups.

Clinical presentation of pseudomyxoma peritonei.

BACKGROUND AND AIMS: We analysed the clinical symptoms and signs of pseudomyxoma peritonei (PMP), a rare syndrome affecting one to two persons per million annually. Presumably, patients with PMP would benefit from early diagnosis. This study was conducted to further characterise the manifestations of PMP. MATERIAL AND METHODS: We performed a retrospective chart review of a consecutive series of 82 PMP cases at the Helsinki University Central Hospital from June 1984 to September 2009. We then analysed the patients' characteristics, clinical manifestations, indications for surgery and preoperative radiological investigations. RESULTS: The study involved 53 women (65%) and 29 men (35%). The preponderance of women was statistically significant (p = 0.008). Abdominal pain was the most common chief complaint in the initial evaluation with 23% of the cases. The subsequent more common chief complaints were acute abdomen with 21%, increased abdominal girth with 17%, coincidental diagnosis with 13%, other reasons with 13% and newly onset hernia with 12% of the cases. Suspected ovarian tumour was the most common cause for surgery overall, with 26 of 82 initial operations (32%). Of the 82 initial operations, 23 (28%) were performed with a suspicion or diagnosis of PMP. Computed tomography had a sensitivity of 51% in recognising PMP. CONCLUSIONS: While only 28% of patients underwent initial surgery for presumed PMP, the accuracy of preoperative diagnostics was modest. Diagnostics of PMP is challenging due to the mimicking nature of the disease. In case of indistinct intra-abdominal tumour, we recommend, careful patient examination prior to the initial surgery, when possible.

On-line measurements provide more accurate estimates of nutrient loading: a case of the Yläneenjoki river basin, southwest Finland.

Automatic on-line measurement stations for water quality components and water level were equipped with dataloggers and GSM transmitters; the stations were installed at two sites in the Yläneenjoki river basin, SW Finland. Measurements during five seasons in 2006-2007 were conducted to find out whether the produced data would provide more accurate estimates of material and nutrient transport than traditional water sampling. Sensor-based monitoring estimates for transport of total suspended solids (TSS) were clearly higher (difference -6-61%), total phosphorus also higher, and that of nitrate (NO(3)-N) somewhat lower (difference (-51%-4%), as compared with manual sampling based estimates. The winter season studied here was mild i.e. winter-type which is becoming more common in Finland with the changing climate. Sensor-based monitoring proved its benefits particularly in such conditions.

Survival of patients with pseudomyxoma peritonei treated by serial debulking.

AIM: We evaluated the outcome of patients with pseudomyxoma peritonei (PMP) after traditional debulking. PMP is a clinical condition characterized by disseminated intraperitoneal mucinous tumours often accompanied by mucinous ascites derived usually from an appendiceal neoplasm. Patients with PMP have traditionally been treated by serial debulking, but aggressive cytoreduction followed by hyperthermic intraperitoneal chemotherapy is now advocated as standard treatment in PMP. METHOD: The analysis included 33 consecutive patients with PMP who underwent traditional debulking surgery between June 1984 and August 2008. The patient characteristics and details of the treatment were analysed retrospectively. The primary end-point was survival. RESULTS: The overall 5- and 10-year survival rates were 67% and 31% respectively. The patients underwent an average of 3.2 +/- 0.4 operations (range 1-10). Of 33 patients, 23 (70%) underwent only 1-3 operations. The 30-day operative mortality rate was 2.7%. However, four patients (12%) seemed to have achieved long-term disease-free survival of more than 5 years. CONCLUSIONS: The 5-year survival is comparable with results achieved in patients receiving a combination of cytoreductive surgery and intraperitoneal chemotherapy, but in the long term, the latter seems superior.

Surveillance and treatment of duodenal adenomatosis in familial adenomatous polyposis.

BACKGROUND AND STUDY AIMS: Patients with familial adenomatous polyposis (FAP) are at increased risk for duodenal cancer whereas colorectal cancer is largely prevented by prophylactic colectomy. We analyzed the results of endoscopic surveillance and different treatment modalities of duodenal adenomatosis in patients with FAP. PATIENTS AND METHODS: Data on endoscopies, histopathological examinations, and surgical therapies were collected from the medical histories of 129 patients with FAP. The cumulative incidences of duodenal adenomatosis and severe dysplasia and cancer were calculated using Kaplan-Meier analysis. RESULTS: By the age of 60 years, the cumulative incidence was 80% for any adenomatosis and 23% for severe dysplasia or cancer. Duodenal cancer was observed in six patients (4.7%). Fifteen endoscopic excisions in 14 patients, and 19 open duodenotomies in 17 patients were carried out. Later, pancreaticoduodenectomy was undertaken in six (35.3%) of these 17 patients. Altogether, 12 patients (9.3%) underwent pancreaticoduodenectomy. Except for one patient, the indication for surgery was based on follow-up endoscopies, and none of these patients died of duodenal cancer. No postoperative deaths occurred. Seven patients (58.3%) had major complications, four (33.3%) of which were surgical. CONCLUSIONS: The high incidence of severe dysplasia and cancer in duodenal polyps suggests that endoscopic surveillance is essential. Endoscopic polypectomies under sedation anesthesia have partly replaced open duodenotomies. High-risk patients with Spigelman IV adenomatosis or adenomas with persisting severe dysplasia should undergo surgery with pylorus-preserving pancreaticoduodenectomy before invasive cancer develops.

Overlap technique improves results of primary surgery after obstetric anal sphincter tear.

PURPOSE: This study was designed to evaluate prospectively the results of the overlap technique in primary sphincter reconstruction after obstetric tear. METHODS: Obstetric tears in 44 women were operated on with primary overlap reconstruction. These women were investigated six to nine months after the operation. Results were compared with those of a historical control group of 52 women whose obstetric sphincter rupture had been treated with the end-to-end technique. RESULTS: The overlap group had significantly more incontinence symptoms after delivery and repair of the sphincter tear than before delivery (P < 0.0001); however, their incontinence symptoms were significantly fewer than those of the end-to-end group (P = 0.004). The prevalence of persistent rupture of the external anal sphincter was significantly lower in the overlap group (6/44, 13.6 percent) than in the end-to-end group (39/52, 75 percent; P < 0.0001). Internal anal sphincter rupture occurred in 5 patients (11.4 percent) in the overlap group and in 40 patients (76.9 percent) in the end-to-end group (P < 0.0001). CONCLUSIONS: The overlap technique should be adopted as the method of choice for primary sphincter repair after obstetric tear.

Female fertility and childbirth after ileal pouch-anal anastomosis for ulcerative colitis.

BACKGROUND: The aim of this study was to calculate the probability of becoming pregnant after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis, and to evaluate complications during pregnancy and childbirth. METHODS: A questionnaire was posted to 160 women with an IPAA and to 160 controls. The probability of becoming pregnant after IPAA was calculated by the Kaplan-Meier method. RESULTS: Of 54 women who had undergone IPAA surgery, 36 (67 per cent) succeeded in becoming pregnant naturally, compared with 49 (82 per cent) of 60 controls. The probability of pregnancy after 2 years of trying was 56 per cent in the IPAA group and 91 per cent in the control group (P < 0.001). Women in the IPAA group needed infertility investigations more often (24 versus 10 per cent; P = 0.044). In all, 39 (72 per cent) women in the IPAA group and 53 (88 per cent) in the control group bore a child. Twenty-one of 39 women in the IPAA group and 13 of 53 in the control group had a caesarean section (P = 0.005). Anal incontinence after delivery occurred more often in the control group. CONCLUSION: Women with an IPAA mostly suffer a reduction in the probability of conception rather than complete infertility. Because complications during pregnancy and delivery were rare, caesarean section should be based mainly on obstetric indications.