Prevalence of Physiologic Sexual Dysfunction Is High Following Treatment for Rectal Cancer: But Is It the Only Thing That Matters?

BACKGROUND: Although several studies have reported high rates of sexual dysfunction in patients treated for rectal cancer, most studies have been limited by retrospective design, failure to use validate instruments, and a limited number of female patients. OBJECTIVES: The objectives of this study were to 1) prospectively assess changes in sexual function before and after treatment for rectal cancer and 2) identify potential areas for improved care of patients who have rectal cancer with sexual dysfunction. DESIGN: This study is a prospective, longitudinal survey. SETTINGS: This study was conducted at 4 tertiary care academic hospitals. PATIENTS: The patients included had newly diagnosed rectal cancer. MAIN OUTCOME MEASURES: Subjects completed the European Organization for Research and Treatment Quality of Life Cancer Module and Colorectal Cancer Module, International Index of Erectile Function, and Female Sexual Function Index questionnaires before the start of treatment, after the completion of preoperative chemoradiotherapy, and 1 year after surgery. RESULTS: Forty-five patients completed the study, and the overall results showed significant sexual dysfunction in both male and female subjects that continued to increase from baseline up to 1 year after surgery. In male subjects, sexual activity, interest, and enjoyment remained relatively stable, despite increasing sexual problems. However, for female patients, although sexual activity and interest remained relatively stable, sexual enjoyment worsened as sexual problems increased. LIMITATIONS: The study closed before reaching the target sample size owing to lower than anticipated accrual rates. Post hoc analysis included qualitative interviews with patients to explore reasons for low recruitment. CONCLUSIONS: The results of this study show that sexual problems continue to increase up to 1 year after surgery. Despite this, sexual interest in both male and female patients remained relatively unchanged suggesting that other aspects of sexuality, not just physiologic function, also need to be evaluated. Future studies to assist and educate physicians on how to initiate a discussion about sexuality and identify patients in "distress" because of sexual problems are important.

Subtotal colectomy in severe ulcerative and Crohn's colitis: what benefit does the laparoscopic approach confer?

BACKGROUND: Comparative outcome data for laparoscopic and open subtotal colectomy in IBD are lacking and often difficult to interpret owing to low case volumes, heterogeneity in case mix, and variation in laparoscopic technique. OBJECTIVE: This study aimed to determine the safety of laparoscopic subtotal colectomy in severe colitis and to determine whether the laparoscopic approach improved short-term outcomes in comparison with the open approach. DESIGN: This was a retrospective cohort study using data from a prospectively maintained clinical database. SETTING: This study was conducted at a single center, Mount Sinai Hospital, Toronto. PATIENTS: All patients undergoing subtotal colectomy for either ulcerative or Crohn's colitis between 2000 and 2011 were included. INTERVENTION: A standardized operative technique was used for both laparoscopic and open subtotal colectomies. Cases performed by non-laparoscopic surgeons were excluded. MAIN OUTCOME MEASURES: Perioperative outcome measures were operative duration, estimated blood loss, total morphine requirement, and length of postoperative stay. Postoperative outcome measures were the rates of minor and major complications. RESULTS: Laparoscopic subtotal colectomies were performed in 131 of 290 cases (45.2%). Nine patients required conversion to an open procedure (6.9%). The uptake of laparoscopic subtotal colectomy increased from 10.2% in 2000/2001 to 71.7% in 2010/2011. Regression analysis with propensity-score adjustment for operative approach revealed that the operative duration was 25.5 minutes longer in laparoscopic cases (95% CI 12.3-38.6; p < 0.001), but that patients experienced fewer minor complications (OR 0.47; 95% CI 0.23-0.96; p = 0.04) and required less morphine (adjusted difference, -72.8 mg; 95% CI 4.9-141; p = 0.04). LIMITATIONS: The inherent selection bias of this retrospective cohort study may not be accounted for by multivariate analysis with propensity-score adjustment. CONCLUSIONS: Laparoscopic subtotal colectomy is safe and may reduce the rate of minor postoperative complications. The increase in operative duration reflects the technical demands associated with this procedure (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A160).

Proctocolectomy for colorectal cancer--is the ileal pouch anal anastomosis a safe alternative to permanent ileostomy?

PURPOSE: Ileal pouch anal anastomosis (IPAA) is the procedure of choice in patients requiring surgery for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). There are few data on reconstruction with the IPAA in patients with colorectal cancer (CRC). This study assessed the outcomes of the IPAA compared to proctocolectomy and permanent ileostomy (PI) on these patients. METHODS: Between 1983 and 2013, over 2800 patients with CRC have been treated at the Mount Sinai Hospital (MSH). Demographic, surgical, pathological, and outcome data for all patients have been maintained in a database-73 patients were treated for CRC with proctocolectomy: 39 patients with IPAA and 34 patients with PI. Clinical features, pathologic findings, and survival outcomes were compared between these groups. RESULTS: Each group was similar with respect to gender, stage, and histologic grade. Patients undergoing IPAA were significantly younger. The diagnosis leading to proctocolectomy was more commonly UC or FAP in patients treated with IPAA (39/39 vs. 23/34, p = 0.001). Rectal cancer subgroups were similar in age, sex, TNM stage, T-stage, height of tumor, and histologic grade. There was no significant difference in overall or disease free survival between groups for colon or rectal primaries. Analysis using the Cochran-Armitage trend test suggests that utilization of IPAA has increased over time (p = 0.002). CONCLUSIONS: The IPAA is a viable and safe option to select for patients who would otherwise require PI. Increased experience and improved outcomes following IPAA has led to its more liberal use in selected patients.

Peritoneal elastic lamina invasion: limitations in its use as a prognostic marker in stage II colorectal cancer.

Peritoneal involvement in colorectal cancer (CRC) is an adverse prognostic feature, which may prompt consideration of adjuvant chemotherapy in stage II disease. Controversies and challenges surrounding its assessment have led to consideration of peritoneal elastic lamina invasion (ELI) as an alternative marker of advanced local spread. The objectives of this study were (1) to evaluate the prognostic significance of peritoneal ELI in stage II CRC and (2) to determine the feasibility of ELI assessment in routine practice with the use of an elastic stain. Two hundred seventeen patients with stage II CRC (186, pT3; 31, pT4) were assessed for ELI and other established adverse histologic features. Of the pT3 tumors, 31 (16.7%) were ELI positive, 121 (65%) were ELI negative, and 34 (18.3%) lacked an identifiable elastic lamina. There were no significant differences in disease-free survival between pT3 ELI-negative and ELI-positive tumors (P = .517). The disease-free survival of pT4 tumors was significantly lower than that of pT3 ELI-negative tumors (P = .024) and pT3 ELI-positive tumors (P = .026), respectively. The elastic lamina was detected less frequently in right-sided pT3 tumors compared with left-sided tumors (65/91 [71.4%] versus 87/95 [91.6%], P < .001). Right-sided tumors were also associated with a reduction in the staining intensity of the elastic lamina (P < .001). In conclusion, peritoneal ELI was not an adverse prognostic factor in this study. The frequent absence of an identifiable elastic lamina, particularly in right-sided tumors, may limit the use of ELI as a prognostic marker in CRC.

Strictureplasty in selected Crohn's disease patients results in acceptable long-term outcome.

BACKGROUND: Strictureplasty is an alternative to resection in patients with Crohn's disease. OBJECTIVE: The objective of this study was to evaluate the long-term results of patients who have undergone strictureplasty. DESIGN: This is a retrospective cohort study. SETTING: This study was conducted at a tertiary referral center, Mount Sinai Hospital, Toronto, Ontario, Canada. PATIENTS: All patients who had a strictureplasty of the small bowel between 1985 and 2010 were identified from a prospective database. MAIN OUTCOME MEASURES: The main outcomes were short-term complications, need for further surgery, and surgery-free survival. Multivariate analysis was performed to determine factors affecting the need for further surgery. Quality of life was measured by use of the short version of the Inflammatory Bowel Disease Questionnaire. RESULTS: Ninety-four patients (42 women; age at first strictureplasty, 33.4 ± 9.7 years) underwent 119 operations (range per patient, 1-4). The number of strictureplasties was 278 (range, 1-11), including 9 in the duodenum and 269 in the jejunum-ileum. The most common type of procedure was the Heineke-Mickulicz (258, 92.8%). Median follow-up of the patients was 94 months (interquartile range, 27-165 months). The surgery-free survival at 5 and 10 years was 70.7% (95% CI 59.8, 81.7) and 26.6% (95% CI 13.6, 39.6). In multivariate analysis, only age at the time of first strictureplasty was associated with the need for further surgery. Fifty-seven (64.8%) patients returned the questionnaire. The average score was 5.2 ± 1.2 (range, 2.2-7.0) with no significant differences between patients with or without previous surgery (p = 0.22), with or without simultaneous resection (p = 0.71) or with or without further surgery (p = 0.11). LIMITATIONS: This study was limited by its sample size and retrospective design. CONCLUSIONS: Strictureplasty is a safe procedure with acceptable long-term outcomes. The risk of needing further surgery is high, which reflects the complexity of this disease. Younger age is associated with a higher risk of need for further surgery. However, most patients have a satisfactory quality of life.

Favorable pathologic and long-term outcomes from the conventional approach to abdominoperineal resection.

BACKGROUND: Suboptimal oncologic outcomes from abdominoperineal resection have been related to high rates of circumferential margin involvement. The extralevator approach has gained popularity as a means of reducing circumferential margin involvement, but it remains unknown whether comparable outcomes are achievable with a conventional approach to abdominoperineal resection. OBJECTIVE: This study aimed to determine the rate of circumferential margin involvement, to identify factors predictive for a positive circumferential margin, and to relate these findings to long-term outcomes. DESIGN: This is a retrospective analysis of a prospective clinical database. SETTINGS: This study was conducted at a single center, Mount Sinai Hospital, Toronto. PATIENTS: Patients were included who underwent abdominoperineal resection for low rectal adenocarcinoma between 1997 and 2006. MAIN OUTCOME MEASURES: The main outcome measures included the rate of circumferential margin involvement, local recurrence, and disease-free survival. RESULTS: A total of 115 patients underwent abdominoperineal resection for primary adenocarcinoma of the rectum. A positive circumferential margin was demonstrated in 18 patients (15.7%). Intraoperative perforations occurred in 7 patients (6.1%). Tumors located anteriorly had a higher rate of circumferential margin involvement (31.6%) compared with lateral (13%), posterior (10%), and circumferential tumors (0%) (P = .024). This finding was reflected by a reduced median distance to the circumferential margin in anterior tumors. Curative resections (n = 108) were followed up for a median of 55.5 months. The 5-year local recurrence rate was 10.6% and the 5-year disease-free survival was 67.4%. Cox regression analysis revealed that circumferential margin involvement was an independent predictor for local recurrence; and T-category, N-category, and circumferential margin involvement for disease-free survival. LIMITATIONS: This study was limited by its sample size and the number of outcome events. CONCLUSIONS: The conventional approach to abdominoperineal resection can produce oncologic outcomes comparable to the extralevator approach. However, the rate of circumferential margin involvement is higher than in restorative procedures and may be related to difficulties in obtaining adequate clearance in anterior tumors.

Assessing outcomes following surgery for colorectal cancer using quality of care indicators.

BACKGROUND: We sought to assess the feasibility of applying Cancer Care Ontario's quality of care indicators to a single institution's colorectal cancer (CRC) database. We also sought to assess their utility in identifying areas that require improvement. METHODS: We included patients who had surgery for CRC between 1997 and 2006 at Mount Sinai Hospital, Toronto, Ont. We excluded patients who had transanal excisions, carcinoma in situ or recurrences that required pelvic exenteration, as well as those whose information was incomplete. We obtained data from a prospective database and verified the data with hospital and office charts. We evaluated trends over a 10-year period using the Cochran-Armitage trend test. RESULTS: During the study period there were 1005 surgical procedures performed in 987 patients with a mean age of 65.6 (standard deviation 15) years; the male:female ratio was 1:2. The most frequent tumour sites were the rectum and sigmoid colon (68%). Over the 10-year period, 9 indicators improved, including the proportion of patients with CRC identified by screening (p < 0.001), the proportion of patients who received preoperative liver imaging (p = 0.05), the proportion of rectal cancer patients who received preoperative pelvic imaging (p = 0.04), the proportion of patients with stage II or III rectal cancer who received radiotherapy (p = 0.03), the proportion of surgical specimens with more than 12 lymph nodes (p < 0.001), the proportion of pathology reports that included quantitative distal (p = 0.004) and radial (p < 0.001) margin measurements, the proportion of patients with an anastomotic leak (p = 0.03), the proportion of patients who received a colonoscopy 1 year after surgery (p < 0.001) and the proportion of operative reports that were complete (p < 0.001). CONCLUSION: The use of quality of care indicators to assess the quality of colorectal surgery is feasible. This study provides benchmarks that can be used to assess changes in the quality of CRC care at our institution.

Sepsis is a major predictor of failure after ileal pouch-anal anastomosis.

PURPOSE: This study aimed to determine the risk of ileal pouch-anal anastomosis failure and factors predictive of failure overall and in patients with septic complications. METHODS: Patients were identified through a prospectively maintained patient registry. All patients registered in the Mount Sinai Hospital Inflammatory Bowel Disease database who had an ileal pouch-anal anastomosis for more than 12 months were included in the study. Pouch failure was defined as ileal pouch-anal anastomosis excision or permanent diversion. Cox proportional hazard models with death as a competing risk were created, modeling time to failure as the outcome of interest for all patients and for the subgroup of patients with septic complications. RESULTS: The study included 1,554 patients. One hundred six patients experienced an ileal pouch-anal anastomosis failure (6.8%), 49 (46.2%) of these failures were caused by septic complications. Independent predictors of failure included Crohn's disease (hazard ratio 7.5, 95% confidence interval [4.7, 12.0]) and postoperative sepsis (hazard ratio 6.6, 95% confidence interval [4.4, 9.8]). In the subgroup of patients with failure due to postoperative septic complications, independent predictors of failure were Crohn's disease (hazard ratio 2.7, 95% confidence interval [1.3, 5.7]) and presence of a pouch fistula (hazard ratio 2.6, 95% confidence interval [1.3, 5.2]). CONCLUSION: Septic complications are the most common cause of ileal pouch-anal anastomosis failure. Careful patient selection and the prevention of septic complications may decrease the risk of this failure.

Validation of an English version of the Padova quality of life instrument to assess quality of life following ileal pouch anal anastomosis.

OBJECTIVE: Ileal pouch anal anastomosis (IPAA) is the procedure of choice for most patients requiring surgery for ulcerative colitis and familial adenomatous polyposis because of its perceived improvement in health-related quality of life (HRQL). The aims of this cross-sectional study were to validate an English version of the Padova Inflammatory Bowel Disease Quality of Life questionnaire (PIBDQL) in patients undergoing IPAA and to investigate the pre- and postoperative predictors of long-term HRQL. MATERIALS AND METHODS: In May 2005, the English version of the PIBDQL, Short Inflammatory Bowel Disease Questionnaire, and the SF-36 were mailed to 1,379 patients who underwent IPAA at the Mount Sinai Hospital between 1982 and 2004. The test-retest reliability, internal consistency, construct validity, and discriminative ability of the English version of the PIBDQL were assessed. RESULTS: Nine hundred fifty-five patients (69%) (475 female, 480 male; mean, age 43 years) returned the questionnaires. The mean PIBDQL score was 21.1 (3.4), suggesting good quality of life. Test-retest reliability [intraclass correlation coefficient (ICC) = 0.784] and internal consistency (Cronbach's alpha = 0.83) were good. Construct validity and discriminative ability of the English version of PIBDQL were adequate. Multivariate analysis revealed that women (p < 0.01) and Crohn's disease patients (p < 0.01) had significantly worse PIBDQL scores. CONCLUSIONS: The English version PIBDQL is a reliable and valid disease-specific instrument for assessing quality of life in patients with IPAA. In this series, female gender and CD were significant predictors of worse HRQL.

A prospective evaluation of sexual function and quality of life after ileal pouch-anal anastomosis.

PURPOSE: This study was designed to assess the effect of ileal pouch-anal anastomosis on sexual function and quality of life in men and women. METHODS: Sexual function of patients undergoing ileal pouch-anal anastomosis from February 2005 to June 2006 was prospectively evaluated using the International Index of Erectile Function in men and Female Sexual Function Index in women. Quality of life was assessed using the Short Inflammatory Bowel Disease Questionnaire. Preoperative scores were compared with scores at 6 and 12 months postoperatively. RESULTS: Of 110 patients eligible for inclusion, 59 (53.6 percent) agreed to participate. Male sexual function and erectile function scores remained high 12 months after surgery (mean International Index of Erectile Function score 51.7 preoperative vs. 58.3 at 12 months postoperative; P = not significant (NS)). Abnormal sexual function decreased from 33.3 percent before surgery to 22.7 percent 12 months after surgery (P = NS). Female sexual function improved 12 months after surgery (mean Female Sexual Function Index score 19.2 preoperative vs. 27 at 12 months postoperative; P = 0.031). Abnormal sexual function decreased from 73.1 percent before surgery to 25 percent 12 months after surgery (P = 0.001). Quality of life significantly improved after ileal pouch-anal anastomosis in both sexes. CONCLUSIONS: In men, ileal pouch-anal anastomosis does not have an adverse effect on sexual function, whereas sexual function in women seems to improve 12 months after surgery.

Improved outcome due to increased experience and individualized management of leaks after ileal pouch-anal anastomosis.

OBJECTIVE: To assess the clinical presentation, management, and outcome of leaks after the ileal pouch-anal anastomosis (IPAA) procedure. METHODS: Of 1424 IPAA procedures performed at Mount Sinai Hospital from 1981 to 2003, 141 patients experienced leaks (9.9%). Data were reviewed retrospectively from the Inflammatory Bowel Disease database and clinic and hospital charts. Statistical comparisons were performed with the chi2 test. RESULTS: There were 81 men and 60 women with a median age of 36 years (12-69). Indication for surgery was ulcerative colitis in 93% of patients. Twenty-three leaks (16.3%) originated from the pouch whereas 118 (84.1%) arose from the ileoanal anastomosis. Of ileoanal anastomosis leaks, 24.6% were associated with and 38.1% without an abscess, 12.7% were associated with a pouch-cutaneous fistula, 15.3% were associated with a pouch-vaginal fistula, and 9.3% were diagnosed radiologically. Of the 130 patients who developed symptoms, 67% had fever, 38% had abdominoperineal pain, and 6% had perineal abscess. Twenty-nine percent of those who did not have an ileostomy had increased stool frequency. Nonoperative treatment was attempted initially in 100 patients with an 80% success rate. An operative procedure was performed in 59 patients (including those who failed nonoperative treatment), including transanal repair in 34 patients with a success rate of 66%; laparotomy with direct suture repair in 7 with a success rate of 57% and combined abdominoperineal pouch reconstruction in 18 with a success rate of 72%. Overall, 119 patients (84%) have a functioning pouch. Pouch salvage after a leak increased from 67% in 1981-1984 to 88% in 2001-2003 (P = 0.0004, chi2). CONCLUSIONS: A high rate of ileal pouch salvage can be achieved after leaks associated with the IPAA procedure if management is individualized. Improved salvage rate over time is likely a reflection of increased experience with the management of complications as well as the strategy of individualized management.

Lateral internal sphincterotomy is superior to topical nitroglycerin for healing chronic anal fissure and does not compromise long-term fecal continence: six-year follow-up of a multicenter, randomized, controlled trial.

PURPOSE: Although there is enthusiasm for nonoperative management of anal fissures, most trials have been of short duration (6-8 weeks) and long-term outcome is unknown. The purpose of this study was to assess long-term outcome in two cohorts of patients who had participated in a randomized, controlled trial to compare the effectiveness of topical nitroglycerin with internal sphincterotomy in the treatment of chronic anal fissure. METHODS: Between February 1997 and October 1998, 82 patients with chronic anal fissure were accrued and randomized to 0.25 percent nitroglycerin ointment t.i.d. or lateral internal sphincterotomy. In 2004, a telephone survey of trial participants was conducted to determine symptom recurrence, the need for further medical and/or surgical treatment, and patient satisfaction. Furthermore, patients were assessed for symptoms of fecal incontinence using the Jorge and Wexner Fecal Incontinence Score and the Fecal Incontinence Quality of Life questionnaire. RESULTS: Overall, 51 of the original 82 patients (62 percent, 27 nitroglycerin, 24 lateral internal sphincterotomy) completed our survey. Mean follow-up was 79 (+/-1) months. Sphincterotomy patients were less likely to have experienced fissure symptoms within the past year (0 vs. 41 percent; P = 0.0004) and were less likely to require subsequent surgical treatment (0 vs. 59 percent; P < 0.0001) than patients treated with nitroglycerin. Patients in the lateral internal sphincterotomy group were more likely to say that they were "very" or "moderately" satisfied with their treatment (100 vs. 56 percent; P = 0.04) and that they would choose the same treatment again (92 vs. 63 percent; P = 0.02) than patients in the nitroglycerin group. Finally, the fecal incontinence and fecal incontinence quality of life scores at six-year follow-up were similar in both groups. CONCLUSIONS: After six years of follow-up, it seems that lateral internal sphincterotomy is a more durable treatment for chronic anal fissure compared with topical nitroglycerin therapy and does not compromise long-term fecal continence. Thus, sphincterotomy continues to be a good treatment for patients with chronic anal fissure.

Complications and sexual function after vaginectomy for anorectal tumors.

PURPOSE: The objective of this study was to determine complication rates and functional outcomes of females who underwent vaginectomy during anorectal tumor resection and to determine whether flap reconstruction of the vagina improves sexual function. METHODS: A retrospective review was performed of all females who underwent multivisceral resections involving the vagina for anorectal tumors at two academic hospitals from 1985 to 2004. Living patients were contacted, and a 25-question telephone questionnaire was administered. RESULTS: Fifty-four patients were identified. Nineteen patients had flap reconstruction of the vagina and 35 had primary repair. Eighty-three percent of patients experienced surgical complications, including perineal wound complications in 33 percent (14/42) of those with perineal incisions and vaginal complications in 41 percent (22/54) of the cohort. There was a nonsignificant decrease in perineal wound complications when flap reconstruction was performed (22 vs. 42 percent). Twenty-three patients completed the questionnaire (96 percent of those eligible). Six patients were able to have sexual intercourse after surgery and nine were not. Reasons for inability to have sexual intercourse were: inadequate vaginal capacity (n = 4), pain (n = 2), and chronic wound or fistula (n = 3). No living patients who had flap reconstruction were able to have sexual intercourse. Only 20 percent of patients remembered a preoperative discussion of possible sexual effects of surgery; however, overall quality of life was preserved. CONCLUSIONS: Anorectal tumor resections involving the vagina are associated with a high rate of complications, including inability to have intercourse after surgery, even with flap reconstruction. Females should be counseled regarding potential loss of sexual function.

Prevalence of male and female sexual dysfunction is high following surgery for rectal cancer.

OBJECTIVE: To measure sexual function and quality of life (QOL) after rectal cancer treatment. SUMMARY BACKGROUND DATA: Previous studies on sexual function after rectal cancer treatment have focused on males and have not used validated instruments. METHODS: Patients undergoing curative rectal cancer surgery from 1980 to 2003 were administered a questionnaire, including the Female Sexual Function Index (FSFI) or International Index of Erectile Function (IIEF), and the EORTC QLQ-C30/CR-38. Multiple logistic regression was used to test associations of clinical factors with outcomes. RESULTS: Eighty-one women (81.0%) and 99 men (80.5%) returned the questionnaire; 32% of women and 50% of men are sexually active, compared with 61% and 91% preoperatively (P < 0.04); 29% of women and 45% of men reported that "surgery made their sexual lives worse." Mean (SD) FSFI and IIEF scores were 17.5 (11.9) and 29.3 (22.8). Specific sexual problems in women were libido 41%, arousal 29%, lubrication 56%, orgasm 35%, and dyspareunia 46%, and in men libido 47%, impotence 32%, partial impotence 52%, orgasm 41%, and ejaculation 43%. Both genders reported a negative body image. Patients seldom remembered discussing sexual risks preoperatively and seldom were treated for dysfunction. Current age (P < 0.001), surgical procedure (P = 0.003), and preoperative sexual activity (P = 0.001) were independently associated with current sexual activity. Gender (male, P = 0.014), surgical procedure (P = 0.005), and radiation therapy (P = 0.0001) were independently associated with the outcome "surgery made sexual life worse." Global QOL scores were high. CONCLUSIONS: Sexual problems after surgery for rectal cancer are common, multifactorial, inadequately discussed, and untreated. Therefore, sexual dysfunction should be discussed with rectal cancer patients, and efforts to prevent and treat it should be increased.

Crohn's disease and indeterminate colitis and the ileal pouch-anal anastomosis: outcomes and patterns of failure.

PURPOSE: This study was designed to determine the outcome of patients with Crohn's disease and indeterminate colitis who have an ileal pouch-anal anastomosis. METHODS: Between 1982 and 2001, 1,270 patients underwent a restorative proctocolectomy at the Mount Sinai Hospital: 1,135 had ulcerative colitis, 36 had Crohn's disease, 21 had indeterminate colitis, and 78 had another diagnosis. Perioperative data were collected prospectively. Functional outcomes were assessed with a 35-question survey mailed to all patients with a functioning pouch of at least six months duration. RESULTS: Pouch complications were significantly more common in patients with Crohn's disease (64 percent) and indeterminate colitis (43 percent) compared with patients with ulcerative colitis (22 percent) (P < 0.05). Similarly, 56 percent of patients with Crohn's disease had their pouch excised or defunctioned, compared with 10 percent of patients with indeterminate colitis and 6 percent with ulcerative colitis (P < 0.01). In the subgroup of patients with a diagnosis of Crohn's disease, multivariate analysis revealed that the pathologist's initial designation of ulcerative colitis (based on the colectomy specimen) and an increasing number of pathologic, clinical, and endoscopic features of Crohn's disease were independently associated with pouch failure. The functional results in patients with Crohn's disease with a successful pouch were not significantly different from those with indeterminate colitis or ulcerative colitis. CONCLUSIONS: Although complication rates may be higher in patients with indeterminate colitis compared with ulcerative colitis, the overall pouch failure rate is similar. On the other hand, more than one-half of patients with Crohn's disease will require pouch excision or diversion. Our data suggest that it is difficult to identify patients with Crohn's disease who are likely to have a successful outcome after restorative proctocolectomy. Thus, Crohn's disease should remain a relative contraindication to restorative proctocolectomy, whereas ileal pouch-anal anastomosis is an acceptable alternative for patients with indeterminate colitis.

Pouch-vaginal fistula after ileal pouch-anal anastomosis: treatment and outcomes.

PURPOSE: Pouch-vaginal fistula is an uncommon but serious complication after ileal pouch anal anastomosis. The management of pouch-vaginal fistulas is challenging and a number of treatment options exist. The purpose of this study was to examine the outcomes after various procedures for pouch-vaginal fistula performed at our institution. METHODS: Patients who were treated for pouch-vaginal fistula at Mount Sinai Hospital were identified from a prospectively maintained database. Demographic, disease history, treatment, and outcomes data were obtained. Treatment success was defined as no recurrence of the fistula with a functioning pouch and no ileostomy. RESULTS: Since November 1982, 24 of 619 (3.9 percent) women who had primary ileal pouch-anal anastomosis performed at Mount Sinai Hospital developed a pouch-vaginal fistula. Five women had ileal pouch-anal anastomosis performed at another institution and were referred for management of their pouch-vaginal fistula. Local and/or combined abdominoperineal repairs were performed in 22 of 29 patients. Combined abdominoperineal repairs were associated with a higher success rate than that of local perineal repairs (52.9 vs. 7.9 percent, respectively, at 10 years after repair; p = 0.035). Overall, 50 percent (11/22) of patients who underwent surgical repair of a pouch-vaginal fistula had a successful result with a functioning pouch and no recurrence of the fistula, and 21 percent (6/29) of patients required pouch excision. CONCLUSIONS: The management of pouch-vaginal fistula after ileal pouch-anal anastomosis is associated with a high recurrence rate. Combined abdominoperineal repair appears to offer better results than those of local procedures.

Risk of small bowel obstruction after the ileal pouch-anal anastomosis.

OBJECTIVE: To determine the incidence of small bowel obstruction (SBO), to identify risk factors for its development, and to determine the most common sites of adhesions causing SBO in patients undergoing ileal pouch-anal anastomosis (IPAA). METHODS: All patients undergoing IPAA at Mount Sinai Hospital were included. Data were obtained from the institution's database, patient charts, and a mailed questionnaire. SBO was based on clinical, radiologic, and surgical findings. Early SBO was defined as a hospital stay greater than 10 or 14 days because of delayed bowel function, or need for reoperation or readmission for SBO within 30 days. All patients readmitted after 30 days with a discharge diagnosis of SBO were considered to have late SBO. RESULTS: Between 1981 and 1999, 1,178 patients underwent IPAA (664 men, 514 women; mean age 40.7 years). A total of 351 episodes of SBO were documented in 272 (23%) patients during a mean follow-up of 8.7 years (mean 1.29 episodes/patient). Fifty-four patients had more than one SBO. One hundred fifty-four (44%) of the SBOs occurred in the first 30 days; 197 (56%) were late SBOs. The cumulative risk of SBO was 8.7% at 30 days, 18.1% at 1 year, 26.7% at 5 years, and 31.4% at 10 years. The need for surgery for SBO was 0.8% at 30 days, 2.7% at 1 year, 6.7% at 5 years, and 7.5% at 10 years. In patients requiring laparotomy, the obstruction was most commonly due to pelvic adhesions (32%), followed by adhesions at the ileostomy closure site (21%). A multivariate analysis showed that when only late SBOs were considered, performance of a diverting ileostomy and pouch reconstruction both led to a significantly higher risk of SBO. CONCLUSIONS: The risk of SBO after IPAA is high, although most do not require surgical intervention. Thus, strategies that reduce the risk of adhesions are warranted in this group of patients to improve patient outcome and decrease healthcare costs.