Systematic review of the literature on the quality of life of patients with reconstructive surgery for inflammatory bowel disease

The only curative treatment for ulcerative colitis is proctocolectomy. For this reason, over time, multiple techniques have been studied to obtain the best possible functionality and quality of life, which has being highly affected by the disease. The techniques presented for study are ileoanal anastomosis with pouch and ileostomy, considering at the beginning the pouch as the best technique. Results obtained from the variables studied: fertility is less affected in the ileostomy, sexual function did not present differences, the frequency of bowel movements in the pouch is 6-7 bowel movements per day with an incontinence of approximately 21%, and the economic impact is much more pronounced in the ileostomy, while irritation and pain is much more frequent in the ileostomy. With regard to psychosocial function, there is some variability in the results without a clear difference between the two techniques. With regard to the quality of life assessed by the tests, there is a slight improvement in the pouch compared to the state before the operation. As a conclusion, we can formulate different alternatives, in young women with genetic desire the best option is the ileostomy, while in the rest of the patients, and the ileoanal anastomosis with pouch presents an adequate quality of life

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The impact of ileal pouch-anal anastomosis on graft survival following liver transplantation for primary sclerosing cholangitis.

BACKGROUND: Liver transplantation is the only life-extending intervention for primary sclerosing cholangitis (PSC). Given the co-existence with colitis, patients may also require colectomy; a factor potentially conferring improved post-transplant outcomes. AIM: To determine the impact of restorative surgery via ileal pouch-anal anastomosis (IPAA) vs retaining an end ileostomy on liver-related outcomes post-transplantation. METHODS: Graft survival was evaluated across a prospectively accrued transplant database, stratified according to colectomy status and type. RESULTS: Between 1990 and 2016, 240 individuals with PSC/colitis underwent transplantation (cumulative 1870 patient-years until first graft loss or last follow-up date), of whom 75 also required colectomy. A heightened incidence of graft loss was observed for the IPAA group vs those retaining an end ileostomy (2.8 vs 0.4 per 100 patient-years, log-rank P = 0.005), whereas rates between IPAA vs no colectomy groups were not significantly different (2.8 vs 1.7, P = 0.1). In addition, the ileostomy group experienced significantly lower graft loss rates vs. patients retaining an intact colon (P = 0.044). The risks conferred by IPAA persisted when taking into account timing of colectomy as related to liver transplantation via time-dependent Cox regression analysis. Hepatic artery thrombosis and biliary strictures were the principal aetiologies of graft loss overall. Incidence rates for both were not significantly different between IPAA and no colectomy groups (P = 0.092 and P = 0.358); however, end ileostomy appeared protective (P = 0.007 and 0.031, respectively). CONCLUSION: In PSC, liver transplantation, colectomy + IPAA is associated with similar incidence rates of hepatic artery thrombosis, recurrent biliary strictures and re-transplantation compared with no colectomy. Colectomy + end ileostomy confers more favourable graft outcomes.

[The current place of abdomino-anal pull-through resection of the rectum in the modern rectal cancer surgery].

It was discussed abdomino-anal resection of rectum with relegation of colon excess in anal canal in case of cancer. It was presented the data about state of colo-anal functions in patients after such operations. The reasons of unsatisfactory functional results are analyzed in the article. Also it was described the factors influencing on violation of tank, evacuation and obturator functions.

Pouch function and gastrointestinal complications during pregnancy after ileal pouch-anal anastomosis.

OBJECTIVE: To estimate the risk of gastrointestinal and pouch complications and alterations in pouch function related to pregnancy in women treated with ileal pouch-anal anastomosis (IPAA). METHODS: Pregnancies following IPAA were identified in our center, and in the literature through MEDLINE and PUBMED searches. The incidence of each complication was calculated. Pouch function was compared before and after pregnancy, by mode of delivery, and between women who became pregnant versus those that did not. RESULTS: The incidence of complications in 283 pregnancies after IPAA was 12.7% including antepartum (2.8%) or postpartum (6.7%) small bowel obstruction, pouchitis (1.8%), and perianal abscess (0.4%). Stool frequency and incontinence were not significantly affected by pregnancy or mode of delivery. CONCLUSION: Pregnancy after IPAA is overall safe, associated with limited complications and no significant alteration in pouch function. Vaginal delivery appears as safe as cesarean section for most women.

Treatment of severe childhood constipation with restorative proctocolectomy.

OBJECTIVE: To describe the clinical features of children with severe constipation and their outcome after restorative proctocolectomy. DESIGN: Observational study and health status questionnaire using gastrointestinal quality of life score (GIQL). SETTING: English regional paediatric surgery service. PATIENTS: Five children were identified, with severe constipation, whose symptoms had not improved with either prolonged medical therapy or colonic lavage using an antegrade colonic enema procedure. All had required a stoma to resolve their constipation. Intervention All underwent restorative proctocolectomy. RESULTS: All children are stooling through their anus. The mean stool frequency is 6/day. None have daytime incontinence, and none require any further therapy for constipation. Complication rates have been low with no permanent morbidity. The mean GIQL 3 years following restorative proctocolectomy was 89 (SD 29). CONCLUSIONS: In highly selected cases, restorative proctocolectomy may allow resolution of the symptoms of severe constipation and avoid leaving a child with a permanent stoma.

A phenomenological study of the postoperative experiences of patients undergoing surgery for colorectal cancer.

PURPOSE: This study was designed to investigate patients' experience during the postoperative phase of recovery following colorectal resection with end-to-end anastomosis. METHOD AND SAMPLE: This was a descriptive phenomenological study reliant upon individual interviews. The sample was purposefully drawn from those admitted for surgery. Interviews continued until no new data could be identified from the transcripts. KEY RESULTS: After initial relief that surgery was over, the experience was dominated by 'tubes and drains', the consequences of epidural anaesthesia and ongoing pain relief. Themes encompassed loss of dignity and control, inability to eat and drink and lack of sleep. Some found it embarrassing discussing and coping with intimate bowel issues in a communal environment, particularly in mixed sex wards. Patients' emotional state initially reflected their physical condition rather than their disease; as independence was regained, awareness that they were suffering from cancer recurred and was associated with fear and anxiety. Variations in requirements for information were evident indicating that communication does not always equate with understanding. Participants passed through a stage of complete dependence to a degree of renewed independence at discharge, which was itself associated with mixed emotions. For some, there was relief while others were anxious about leaving the 'safety' of the hospital environment. CONCLUSIONS: These findings provide considerable insight into the experience of colorectal surgery and so can make a significant contribution to the planning and delivery of care; they have the potential to impact on the care received by those with colorectal cancer.

Functional outcome and quality of life after restorative proctocolectomy and ileo-anal pouch anastomosis.

OBJECTIVE: Reconstructive proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical treatment of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). The aim of our study was to evaluate the functional results of this procedure and to assess its impact upon patient quality of life (QoL). METHODS: We evaluated QoL and functional results in patients who had undergone IPAA using two self-rating questionnaires: 1) Medical Outcome 36 item Health Survey (SF-36); and 2) a specific questionnaire evaluating various aspects of anorectal and urogenital function. RESULTS: 107 patients (median age 38 [range 17-69] years) underwent reconstructive proctocolectomy with IPAA between 1981 and 2002. Median duration of follow-up was 83 (range 4-230) months. 66 patients (61%) answered both questionnaires. Two thirds of patients have more than five bowel movements per day and one bowel movement at night. Whilst true faecal incontinence is exceptional, episodes of soiling are reported by 25% of patients. Regarding QoL in this population, the two scores of the SF-36, which summarise physical and mental health status (Physical Component Summary and Mental Component Summary) were 54.6 and 45.8, respectively (both are 50 in the general population). CONCLUSION: Our data indicate that, as measured with SF-36 questionnaire, QoL after IPAA is close to normal. However, good quality of life is not a surrogate for good functional results. Despite excellent control of continence during the day, IPAA is often associated with night time bowel movements and soiling.

Recommended follow-up for ileo-anal pouch patient.

One of the greatest advances in colorectal surgery over the past 30-years has been the development of restorative proctocolectomy with ileal pouch-anal anastomosis for patients suffering with ulcerative colitis and selected patients with familial adenomatous polyposis. This has coincided with a proliferation of new and exciting advanced clinical roles for nurses in the United Kingdom and subsequently has led to an increase in the responsibilities and professional status of nurses. Staff development is necessary to maintain the unique contribution that nurses make to health care in the terms of practice, education and research. Nurse specialists in gastroenterology are taking their place alongside medical specialists, and more importantly establishing themselves as the principle carer in many diverse roles. However, as these nursing roles expand, a recognized framework needs to be designed, which takes into account the educational, ethical and legal issues related to accountability of running nurse-led clinics, offering support, advice and follow-up for patients. This article provides nursing staff with research-based recommendations and practical guidance on running a successful nurse-led pouch clinic and follow-up service in collaboration with the consultant surgeon, gastroenterology teams and nursing staff involved specifically with the ileo-anal pouch patient.

Comprehensive pouch clinic concept for follow-up of patients after ileal pouch anal anastomosis: report of 3 years' experience in a tertiary referral center.

BACKGROUND: We designed and evaluated a novel concept in enhancing postoperative care of patients following restorative proctocolectomy (RPC) for ulcerative colitis (UC) and determined the risk factors, incidence, and nature of RPC-associated complications in this population. METHODS: The study cohort consisted of consecutive UC patients post-RPC attending a comprehensive pouch clinic run by a gastroenterologist and a colorectal surgeon in a tertiary care medical center (from January 2003 to December 2005). Data were collected on their medical history, physical examination, laboratory tests, pouch endoscopy and biopsies, and anonymous in-house patient satisfaction questionnaires mailed to the first 90 patients. Assessment was also done on data regarding risk factors, incidence, and nature of RPC-associated complications. RESULTS: A total of 120 UC patients with a functioning pouch visited the clinic: mean age 37 years, range 13-75; 57 males; mean disease duration 11 years; mean follow-up 65 months. Of the 55 patients who responded to the questionnaire, 48 (87%) felt that the comprehensive clinic significantly improved the quality of their care. The major complications were pouchitis (52%), extraintestinal manifestations, pouch-related fistula, and mechanical dysfunction. The risk factors for the development of pouchitis were time since surgery, >1-stage surgery, and reason for surgery (acute exacerbation/intractable disease more than dysplasia/cancer); the latter was the only independent risk factor. CONCLUSIONS: The pouch clinic concept significantly enhanced patient satisfaction. The most common RPC-associated complication was pouchitis. Risk factors for developing pouchitis were duration since operation, >1-stage operation, and indication for surgery.

Review article: restorative proctocolectomy, indications, management of complications and follow-up--a guide for gastroenterologists.

BACKGROUND: Restorative proctocolectomy with ileal pouch-anal anastomosis is the procedure of choice for the majority of patients with ulcerative colitis who require surgery. Over 2500 patients in the UK have undergone restorative proctocolectomy. It is now increasingly being performed in district general hospitals as well as in specialist inflammatory bowel disease units. Gastroenterologists are increasingly involved in the management of patients following restorative proctocolectomy. AIM: To provide gastroenterologists with a clear understanding of the investigation and evidence-based management of complications and the aftercare required in patients who have undergone restorative proctocolectomy. RESULTS: Following restorative proctocolectomy, most patients have an excellent long-term functional outcome. Pouchitis, pelvic sepsis and poor function are the most common causes of failure. The development of cancer is rare; nevertheless, long-term follow-up is required. CONCLUSIONS: The investigation and management of patients who develop complications require a multidisciplinary team approach to optimize the outcome. Protocols are suggested for investigation and management of patients with complications and for long-term cancer surveillance.

A longitudinal study of long-term quality of life after ileal pouch-anal anastomosis.

BACKGROUND: There is a lack of longitudinal long-term studies of quality of life (QOL) after surgery with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis, where cohorts of patients are used as their own controls. METHODS: Forty ulcerative colitis patients who had undergone IPAA were prospectively assessed while they had a temporary ileostomy, and at a median of 18 months and 7 years after ileostomy closure. QOL was measured with the Psychosocial Adjustment to Illness Scale and the Well-Being Profile. RESULTS: QOL was good at all three time points and, with some exceptions, did not change significantly between the assessments. There was a high degree of stability in the patients' evaluation of their QOL over time. CONCLUSIONS: QOL was already good when the patients had a temporary ileostomy and generally did neither improve nor deteriorate during 7 years after ileostomy closure. QOL was also quite stable in terms of individual differences.

Restorative proctocolectomy in UK servicemen.

OBJECTIVE: To investigate the outcome of restorative proctocolectomy (RPC) in UK Servicemen and to determine the compatibility of this procedure with Service life. PATIENTS: All Servicemen undergoing restorative proctocolectomy for ulcerative colitis (UC) or familial adenomatous polyposis (FAP) up to December 31st 2000 were identified from Service records. Patients were reviewed by direct or telephone interview. Pouch function, military duties, medical category or reasons for discharge from the Service were recorded. RESULTS: Fifteen Servicemen (6 Royal Navy, 6 Army, 3 RAF), mean age 30 years, underwent RPC for UC (14) or FAP (1) with a median follow-up of 74 months. Eight remain in their Service, five of whom carry out full duties and three restricted duties. Of the seven who have left the Services only one was medically unfit to continue due to poor pouch function whilst six left voluntarily to pursue active civilian careers. Fourteen patients have acceptable pouch function; one pouch has been excised for intractable pouchitis. CONCLUSIONS: Restorative proctocolectomy is compatible with Service life and most individuals are capable of fulfilling active unrestricted military duties.

Functional outcomes in patients with mucosal ulcerative colitis after ileal pouch-anal anastomosis by the double stapling technique: is there a relation to tissue type?

PURPOSE: The aim of this study was to evaluate any differences in functional outcome in patients with mucosal ulcerative colitis after restorative proctocolectomy and ileal pouch-anal anastomosis with use of the double stapling technique relative to the type of tissue in the stapled doughnut. METHODS: Between September 1988 and June 1997, the pathology of all patients with mucosal ulcerative colitis who underwent ileal pouch-anal anastomosis with use of the double stapling technique were reviewed. Information was obtained regarding the tissue types in the distal tissue rings (doughnuts) obtained from the stapled ileal pouchanal anastomosis. The level of anastomosis was classified according to the type of tissue in the distal doughnut: Group I- patients in whom the anal transitional zone was removed and the distal doughnut included squamous epithelium or transitional epithelium and Group II- patients in whom the anal transitional zone was preserved because the distal doughnut revealed only columnar epithelium. Functional outcomes were assessed and compared by detailed questionnaires mailed to all patients at least one year after ileal pouch-anal anastomosis surgery. RESULTS: Distal doughnuts were obtained from the stapled ileal pouch-anal anastomosis in 222 patients with mucosal ulcerative colitis. Follow-up data at a mean of 38 (range, 12-132) months were obtained in 138 (62.2 percent) patients, including 72 males, with a mean age of 46.9 (range, 13-79) years. Group I consisted of 40 patients (29 percent; 35 (25.4 percent) who had squamous epithelium and 5 (3.6 percent) who had transitional epithelium in the distal tissue rings). Group II consisted of 98 patients (71 percent) with columnar epithelium in the distal tissue rings. Age at diagnosis and operation, duration of disease, length of follow-up, and stage of pouch surgery were similar in the two groups. Incontinence scores, frequency of bowel movement, use of a protective pad, discrimination between gas and stool, use of antidiarrheals, life-style alteration, and patient satisfaction showed similar functional results between the two groups. CONCLUSIONS: The tissue type in the stapler distal doughnut did not greatly influence functional outcome. Failure to identify a relationship may attest to the variable height and composition of the anal transitional zone.

Caring for patients with coloanal reservoirs for rectal cancer.

Advances in surgical techniques enable select patients with rectal cancer to have sphincter-saving procedures that restore the continuity of the GI tract, eliminating the need for a permanent colostomy. One of the preferred surgical options is the construction of a coloanal reservoir or colonic J-pouch. This procedure is usually performed in two stages (two surgeries) and involves creating a temporary ileostomy. Patients undergoing treatment for rectal cancer frequently require adjunctive therapy for the disease before and after surgery. They require extensive education and support during the course of treatment and through rehabilitation.

Restorative proctocolectomy for distal ulcerative colitis.

BACKGROUND: Chronic distal colitis may cause troublesome symptoms and alter quality of life. When medical treatment fails to control symptoms, patients and doctors are often reluctant to consider surgical resection because of the relatively small portion of the large bowel affected by the disease. AIM: To assess the outcome of restorative proctocolectomy (RP) in patients with distal colitis who required surgery for chronic debilitating symptoms and failed medical management. PATIENTS/METHODS: From 1986 to 1996, of 263 patients receiving RP for ulcerative colitis, 27 (16 men) were operated on for distal ulcerative colitis limited to the rectum and sigmoid colon. Bowel function and quality of life were compared before and one year after RP. RESULTS: The mean (SD) duration of ulcerative colitis was 11 (6) years. RP was performed at a mean age of 46 (10) years. All the pouches were J-shaped, and a diverting loop ileostomy was always performed. Mean (SD) hospital stay was 25 (10) days. Seven complications occurred in six patients. Previously unknown severe dysplasia was discovered on the colectomy specimen in two patients. After RP there was a significant decrease in mean (SD) daytime stool frequency (8.2 (4) v 4.7 (2), p<0.05), night-time stool frequency (2 (2) v 1 (1), p = 0.05), and the number of patients with urgency to defecate (26/27 v 1/27, p<0.001). Sex life was improved in eight patients, social life in 26, and professional life in eight. Twenty six patients were satisfied with the results, and 25 wished that they had received surgery earlier in the course of their disease. CONCLUSION: RP can improve bowel function and quality of life in patients with disabling chronic symptoms of distal ulcerative colitis.

Functional results of colonic J-pouch anastomosis for rectal cancer.

The purpose of this study was to clarify the functional outcomes of colonic J-pouch anastomosis (J-LAR) for lower rectal cancer in comparison with those of traditional straight anastomosis (S-LAR). A questionnaire regarding anorectal function was conducted 1 year after operation on patients who underwent J-LAR (n = 15) and S-LAR (n = 30). The clinical functions were assessed by an incontinence scoring system. The physiologic function was assessed by anorectal manometry and the balloon expulsion test. No patients demonstrated a diverting stoma. The bowel frequency (range) 1 year after operation was 4.8 (3-6) in the S-LAR group and significantly decreased to 1.8 (1-3) in the J-LAR group (P < 0.05). Complete evacuation was 50.2% (40%-60%) in the S-LAR group and significantly increased to 80.6% (60%-90%) in the J-LAR group (P < 0.05). Neorectal compliance was 2.2 (1.4-2.9) ml/mmHg in the S-LAR group and significantly increased to 3.1 (1.3-3.5) ml/mmHg in the J-LAR group (P < 0.01). No significant difference was observed between the two groups regarding the maximum resting or maximum voluntary squeezing pressure. In conclusion, our findings suggested colonic pouch anastomosis performed after a low anterior resection to support the compliance of the (neo)rectum to be an important factor for retaining a satisfactory bowel frequency.

Evolution of the pelvic pouch procedure at one institution: the first 100 cases.

BACKGROUND: Total extirpation of the colon with pelvic pouch formation, and the avoidance of a permanent stoma, continues to pose a challenge for better results, both technically and functionally. The aims of this study were to investigate the first 100 pelvic ileal-pouch procedures, assessing changes in surgical technique, their relationship to morbidity and long-term outcome, and compare this to the few large international series. METHODS: Between 1984 and 1997, 100 patients had a pelvic J-shaped ileal-pouch formed, 58 two-stage and 42 three-stage procedures. Fifty had a hand-sewn pouch-anal anastomosis and 50 a double-stapled anastomosis. Seventy-three were for ulcerative colitis, five for indeterminate colitis, 20 for familial adenomatous polyposis (FAP), one for multiple primary colorectal cancers, and one for constipation. RESULTS: After a median follow-up of 68 months, 97% of patients still have a functioning pouch. There were two postoperative deaths (one after-pouch formation and one after-stoma closure). Morbidity occurred in 52 patients, including three patients with pouch leaks and three pouch-anal anastomosis leaks (6% leak rate), 27% with a small bowel obstruction (2% early, 20% late, 5% both), a 19% anal stricture rate, and a 9% pouchitis rate. Three pouches have been removed (all for Crohn's disease). Median number of bowel movements per day was six, with 85% of patients reporting a good quality of life. Patients following a double-stapled procedure have less anal seepage and improved continence over those with a hand-sewn ileal pouch-anal anastomosis. CONCLUSIONS: Despite high morbidity rates, pelvic pouch formation provides satisfactory long-term results for patients requiring total proctocolectomy, with functional results and morbidity rates comparable to larger overseas series.