Ulcerative Colitis: Kiran RP

Lian L, Fazio VW, Remzi FH, Shen B, Dietz D, Kiran RP. · Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA. · Dis Colon Rectum. · Pubmed #19617752 No free full text.

Abstract: PURPOSE: Continent ileostomy is considered an alternative for patients with a failed ileal pouch-anal anastomosis. The aim of this study is to investigate outcomes for patients undergoing continent ileostomy after a failed ileal pouch-anal anastomosis at our institution. METHODS: Patients undergoing continent ileostomy after a failed ileal pouch-anal anastomosis were identified from a prospectively maintained pouch database. Quality-of-life scores were obtained by telephone follow-up or office visit and were determined by the Cleveland Global Quality of Life Score. RESULTS: Sixty-four patients were identified between 1982 and 2007. Forty-two percent were male. The median age was 36.5 (range, 14-61) years. Most common diagnoses included ulcerative colitis (n = 44, 68.8%) and Crohn's disease (n = 13, 20.3%). The indication for continent ileostomy was septic pouch complications in 56.3% patients. The previous pelvic pouch was used in 16 (25%) patients. The 30-day complication rate was 31.3%. There were no perioperative deaths. Median follow-up was five years. The long-term dysfunction rate was 50%, the complication rate was 60.9%, and the revision rate 45.3%. The median revision-free interval was 2.8 years (range, 3 months to 19 years) and the retention rate of continent ileostomy was 95.3% (61 of 64). Median continent ileostomy survival time was 4.2 (range, 1-19) years. The median quality-of-life score was 0.77. CONCLUSIONS: Continent ileostomy is possible in patients wishing to avoid an external appliance after pelvic pouch failure. Despite the associated morbidity, most of this select group of highly motivated patients retain their continent ileostomy long-term and are highly satisfied with their choice of continent ileostomy.

Remzi FH, Fazio VW, Kirat HT, Wu JS, Lavery IC, Kiran RP. · Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA. · Dis Colon Rectum. · Pubmed #19279412 No free full text.

Abstract: PURPOSE:: This study evaluated outcomes of patients with abdominal salvage operations for failed ileal pouch-anal anastomosis. METHODS:: Patients undergoing laparotomy for ileoanal pouch salvage were reviewed from a prospectively maintained pouch database and records. RESULTS:: From 1983 to 2007, 241 abdominal reconstructions were performed. The median follow-up was 5 years (range, 0.04-20.8). Diagnoses before primary ileal pouch-anal anastomosis were ulcerative colitis in 187, familial adenomatous polyposis in 22, indeterminate colitis in 20, Crohn's disease in 9, and other in 3. The most common indications for salvage were fistula (n = 67), leak (n = 65), stricture (n = 42) pouch dysfunction (n = 40), pelvic abscess (n = 25). Seventy-one cases had a new pouch constructed. One hundred and seventy cases had the original pouch salvaged. Twenty-nine cases had either pouch excision or ileostomy without pouch excision the result of failure after reconstruction. To assess functional results and quality of life, patients with reconstruction were matched to those with a primary ileal pouch-anal anastomosis. Significantly higher proportions of patients with reconstruction reported seepage during daytime (P = 0.002), at night (P = 0.015), and daytime pad usage (P = 0.02). Other parameters and quality of life were similar between groups. CONCLUSIONS:: Repeat abdominal surgery was a good alternative for pouch failure. Functional and quality of life outcomes were encouraging.

Melton GB, Fazio VW, Kiran RP, He J, Lavery IC, Shen B, Achkar JP, Church JM, Remzi FH. · Digestive Disease Institute, Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA. · Ann Surg. · Pubmed #18936574 No free full text.

Abstract: OBJECTIVE: To assess long-term outcomes after ileal pouch-anal anastomosis (IPAA) in Crohn's disease (CD). SUMMARY BACKGROUND DATA: Although considered the procedure of choice in ulcerative colitis, performance of ileal pouch-anal anastomosis (IPAA) is controversial in CD. METHODS: CD patients were identified from a prospectively maintained IPAA database. Time-to-diagnosis and pouch retention rates were analyzed using Kaplan-Meier curves. Demographic, clinical, and pathologic factors associated with pouch retention were evaluated with log-rank test and Cox proportional hazards model. RESULTS: Two hundred and four CD patients (108 female, median age 33 years, and median follow-up 7.4 years) with primary IPAA were included. CD diagnosis was before IPAA (intentional) in 20(10%), from postoperative histopathology (incidental) in 97(47%) or made in a delayed fashion at median 36 months after IPAA in 87(43%). Overall 10-year pouch retention was 71%. On multivariate analysis, pouch loss was associated with delayed diagnosis (P = 0.03, hazard ratio [HR] 2.6 (95% confidence interval [CI] 1.1-6.5)), pouch-vaginal fistula (P = 0.01, HR 2.8 (95% CI 1.3-6.4)), and pelvic sepsis (P = 0.0001, HR 9.7(95% CI 3.4-27.3)). Patients with retained IPAA at follow-up had near-perfect/perfect continence (72%), rare/no urgency (68%) with median daily bowel movements 7 (range 2-20). Median overall quality of life, quality of health, level of energy, and happiness with surgery were 9, 9, 8, and 10 of 10, respectively. CONCLUSIONS: For CD patients with IPAA, when the diagnosis is established preoperatively or immediately following surgery, pouch loss rates are low and functional results are favorable. Outcomes in patients with delayed diagnosis are worse but half retain their pouch at 10 years with good functional outcomes.

Kiran RP, Remzi FH, Fazio VW, Lavery IC, Church JM, Strong SA, Hull TL. · Department of Colorectal Surgery, Cleveland Clinic Foundation, Desk A30, 9500 Euclid Avenue, Cleveland, OH 44122, USA. · J Gastrointest Surg. · Pubmed #18228111 No free full text.

Abstract: OBJECTIVE: Ileoanal pouch formation (IPAA) can be technically challenging in obese patients, and there is little data evaluating results after the procedure in these patients. We compare outcomes for patients with a body mass index (BMI) > or =30 undergoing IPAA when compared with those for patients with BMI <30. METHODS: Retrospective analysis of prospectively accrued data for patients with BMI > or =30 undergoing IPAA. Patient and disease-related characteristics, complications, long-term function, and quality of life (QOL) using the Cleveland Global Quality of Life scale (CGQL) were determined for this group of patients (group B) and compared with those for patients with BMI <30 (group A). Kruskal-Wallis and Wilcoxon rank sum tests were used to compare quantitative or ordinal data and chi-square or Fisher's exact tests for categorical variables. Long-term mortality and complication rates were estimated using the Kaplan-Meier method with group comparisons performed using log rank tests. RESULTS: There were 345 patients (median BMI 32.7) in group B and 1,671 patients in group A. When the cumulative risk of complications over 15 years was compared, group B patients had a significantly higher chance of getting a complication (94.9% vs 88%, p = 0.006). The rates of pelvic sepsis (6.7% vs 5.3%, p = 0.3), pouchitis (58.1 vs 54.4%, p = 0.9), pouch failure (6% vs 4.5%, p = 0.9), and hemorrhage (5.6% vs 4.8%, p = 0.7) were similar for group B and group A. Group B patients, however, had a significantly higher risk of the development of wound infection (18.8% vs 8.1%, p < 0.001) and anastomotic separation (10.4% vs 5.4%, p < 0.001), whereas group A patients had a higher rate of development of obstruction over time (26.7% vs 22.3%, p = 0.02). Long-term outcome including QOL and function after 15 years was comparable between groups. CONCLUSIONS: Although technically demanding, IPAA can be undertaken in obese patients with acceptable morbidity. Good long-term functional results and QOL that is comparable to nonobese patients may be anticipated.

Kiran RP, O'Brien-Ermlich B, Achkar JP, Fazio VW, Delaney CP. · Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA. · Dis Colon Rectum. · Pubmed #15868233 No free full text.

Abstract: PURPOSE: This study was designed to evaluate the presentation, management, and outcome of peristomal pyoderma gangrenosum at a specialist colorectal unit and develop a strategy for therapy. METHODS: Patients with peristomal pyoderma gangrenosum were identified from a prospectively accrued Institutional Review Board-approved stoma database. Data were collected regarding demographics, disease status, history of illness, time to healing, and treatments used from the database and by chart review. RESULTS: Sixteen patients presented between 1997 and 2002 with peristomal ulceration consistent with a diagnosis of peristomal pyoderma gangrenosum. Diagnosis was predominantly clinically based on a classic presentation of painful, undermined peristomal ulceration. The underlying diagnosis was Crohn's disease in 11 patients, ulcerative colitis in 3, indeterminate colitis in 1, and posterior urethral valves in 1. At the time of development of peristomal pyoderma gangrenosum, the underlying disease was active in 69 percent of patients. Stoma care, ulcer debridement with unroofing of undermined edges, and intralesional corticosteroid injection was associated with a 40 percent complete response rate and further 40 percent partial response rate. Of five patients who received infliximab, four (80 percent) responded to therapy. Complete response after all forms of therapy, including stoma relocation in seven patients, was 87 percent. CONCLUSIONS: Local wound management and enterostomal therapy are extremely important for patients with peristomal pyoderma gangrenosum. Infliximab may provide a useful option for those failing other forms of medical therapy. Relocation of the stoma is reserved for persistent ulceration failing other therapies, because peristomal pyoderma gangrenosum may recur at the new stoma site.

Kiran RP, Delaney CP, Senagore AJ, O'Brien-Ermlich B, Mascha E, Thornton J, Fazio VW. · Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA. · Am J Gastroenterol. · Pubmed #12907333 No free full text.

Abstract: OBJECTIVES: The Short Form 36 (SF-36) questionnaire is the most widely accepted measure of quality of life (QOL); however, it is cumbersome to use and requires complicated analysis. The Cleveland Global Quality of Life (CGQL) is a simpler tool, which has been validated in patients with ulcerative colitis undergoing restorative proctocolectomy. This study validates CGQL in patients with Crohn's disease and determines the correlation of QOL measurement systems with disease activity as measured by the Crohn's Disease Activity Index (CDAI). METHODS: All patients with Crohn's disease presenting to this department between September 2001 and February 2002 were prospectively entered into a database, including demographic data, disease manifestations, Vienna classification, age at diagnosis, and duration of Crohn's disease. SF-36, CGQL, and CDAI scores were entered concurrently. Cronbach's alpha was used to assess the internal consistency among the components of the CGQL score. Correlation among various QOL measures was assessed with Spearman's test. Relationships between QOL measures and various baseline factors were assessed by Wilcoxon rank sum test, Student's t test, Kruskal-Wallis test, and Pearson's test, depending on the type and distribution of data. Change from baseline in the CGQL was assessed with the Wilcoxon signed rank test. RESULTS: One hundred seventy-eight (178) patients were entered into the database, and 169 completed QOL and CDAI data. There was a significant correlation between SF-36 and CGQL. CGQL and SF-36 correlated similarly with CDAI. Neither patient age, gender, or smoking history were associated with CGQL. CONCLUSIONS: CGQL correlates with disease activity and is a simple measure of QOL in Crohn's disease.