Ulcerative Colitis: Lavery IC

Shen B, Remzi FH, Lavery IC, Lashner BA, Fazio VW. · Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA. · Clin Gastroenterol Hepatol. · Pubmed #18237865 No free full text.

Abstract: Both medical and surgical therapies for ulcerative colitis have inherent advantages and disadvantages that must be balanced for patients with moderate to severe disease. Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for the majority of patients with ulcerative colitis who require proctocolectomy. However, adverse sequelae of mechanical, inflammatory, functional, neoplastic, and metabolic conditions related to the pouch can occur postoperatively. Recognition and familiarization of the disease conditions related to the ileal pouch can be challenging for practicing gastroenterologists. Accurate diagnosis and classification of the disease conditions are imperative for proper management and prognosis.

Fazio VW, O'Riordain MG, Lavery IC, Church JM, Lau P, Strong SA, Hull T. · Department of Colorectal Surgery, Cleveland Clinic Foundation, Ohio 44195, USA. · Ann Surg. · Pubmed #10522727 links to  free full text

Abstract: OBJECTIVE: To evaluate prospectively long-term quality of life and functional outcome after restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis, and to evaluate and validate a novel quality-of-life indicator in this group of patients. SUMMARY BACKGROUND DATA: Restorative proctocolectomy with ileal pouch-anal anastomosis is now the preferred option when total proctocolectomy is required for ulcerative colitis or familial adenomatous polyposis, but long-term data on functional outcome and quality of life after the procedure are lacking. METHODS: Patients (n = 977) who underwent RPC with stapled anastomosis for colitis or polyposis coli and who were followed for > or =12 months were included. Quality of life, fecal incontinence, and satisfaction with surgery were prospectively evaluated by structured interview or questionnaire for 1 to 12 years after surgery (median 5.0). Quality of life was scored using the Cleveland Global Quality of Life (CGQL) instrument (Fazio Score). This is a novel score developed over the past 15 years by the senior author. Quality of life was also evaluated in a subgroup of patients with the Short Form 36 (SF-36). The CGQL was validated by determining its reliability, responsiveness, and validity as well as its correlation with the SF-36 score. RESULTS: Postoperative quality of life as measured by SF-36 was excellent and compared well with published norms for the general U.S. population. The CGQL was found to be reliable, responsive, and valid, and there was a high correlation with the SF-36 scores. Using the CGQL, quality of life was shown to increase after the first 2 years after surgery, and there was no deterioration thereafter. The prevalence of perfect continence increased from 75.5% before surgery to 82.4% after surgery, and although this deteriorated somewhat >2 years after surgery, it was no worse than preoperative values. Ninety-eight percent of patients would recommend the surgery to others. CONCLUSIONS: Long-term quality of life after ileal pouch surgery is excellent and the level of continence is satisfactory. This surgery is an excellent long-term option in patients requiring total proctocolectomy. The CGQL is a simple, valid, and reliable measure of quality of life after pelvic pouch surgery and may well be applicable in many other clinical conditions.

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.

Shen B, Remzi FH, Hammel JP, Lashner BA, Bevins CL, Lavery IC, Wehkamp J, Fazio VW. · Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA. · Inflamm Bowel Dis. · Pubmed #18798573 No free full text.

Abstract: BACKGROUND: Crohn's disease (CD) of the pouch can occur in patients with restorative proctocolectomy and ileal pouch-anal anastomosis originally performed for a preoperative diagnosis of ulcerative colitis (UC). CD of the pouch was often observed in patients with a family history of CD. The purpose was to determine whether the family history of CD increased the risk for CD of the pouch in patients who underwent restorative proctocolectomy. METHODS: A total of 558 eligible patients seen in the Pouchitis Clinic were enrolled, including 116 patients with CD of the pouch and 442 patients with a normal pouch or other pouch disorders. Demographic and clinical variables were included in the study. Multivariable logistic regression analyses were performed. RESULTS: The adjusted multivariate logistic analyses revealed that the risk for CD of the pouch was increased in patients with a family history of CD, with an odds ratio (OR) of 3.22 (95% confidence interval [CI] 1.56-6.67), or with a first-degree relative with CD (OR = 4.18, 95% CI, 1.48-11.8), or with a greater number of family members with CD (OR = 2.00 per family member, 95% CI, 1.19-3.37), adjusting for age, gender, smoking status, duration of IBD, duration of having a pouch, and a preoperation diagnosis of indeterminate colitis or CD. In addition, patients of younger age and longer duration of having a pouch had a higher risk for CD of the pouch. A diagnosis of CD of the pouch was associated with a poor outcome, with a greater than 5-fold estimated increased odds of pouch failure (OR = 5.58, 95% CI, 2.74-11.4). CONCLUSIONS: The presence of a family history of CD is associated with an increased risk for CD of the pouch, which in turn has a high risk for pouch failure.

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.

Shen B, Fazio VW, Remzi FH, Bennett AE, Lavery IC, Lopez R, Brezinski A, Sherman KK, Bambrick ML, Lashner BA. · Center for Inflammatory Bowel Disease, Department of Gastroenterology/Hepatology, Cleveland Clinic, Cleveland, OH 44195, USA. · Dis Colon Rectum. · Pubmed #17665259 No free full text.

Abstract: PURPOSE: Crohn's disease of the pouch can occur in patients with colectomy and ileal pouch-anal anastomosis performed for ulcerative colitis. The clinical features of inflammatory, fibrostenotic, and fistulizing Crohn's disease have not been characterized. METHODS: A total of 73 eligible patients with Crohn's disease of the pouch, who were seen in the Pouchitis Clinic, were enrolled: 25 with inflammatory Crohn's disease, 17 with fibrostenotic Crohn's disease, and 31 with fistulizing Crohn's disease. The clinical phenotypes of Crohn's disease were based on a combined assessment of clinical, endoscopic, radiographic, and histologic features. Clinical symptoms, endoscopic and histologic features, and health-related quality-of-life scores were assessed. RESULTS: Demographic and clinical features, including preoperative and postoperative parameters, were similar between the three phenotypes of Crohn's disease of the pouch. The use of nonsteroidal anti-inflammatory drugs, neuropsychiatric drugs, antidiarrheal agents, and Crohn's disease medicines was not different between the three groups. Predominant symptoms, as expected, were significantly different between the three phenotypes: diarrhea and/or pain in 92 percent of patients with inflammatory Crohn's disease, obstructive symptoms in 64.7 percent of patients with fibrostenotic Crohn's disease, and fistular drainage in 51.6 percent of those with fistulizing Crohn's disease (P < 0.0001). There was no statistical difference in quality-of-life scores between the three phenotypes, adjusted for disease activity. There was no significant correlation between quality-of-life and symptom scores in any of the three groups. Although not statistically significant, patients with fistulizing Crohn's disease (16.1 percent) tended to have an increased risk for pouch failure compared with inflammatory (8 percent) or fibrostenotic (5.9 percent) Crohn's disease. CONCLUSIONS: Predominant symptoms were different in clinical phenotypes of Crohn's disease. Each of the three phenotypes of Crohn's disease similarly affected quality-of-life. Fistulizing Crohn's disease may be associated with a higher risk for pouch failure.

Shen B, Fazio VW, Remzi FH, Bennett AE, Lopez R, Lavery IC, Brzezinski A, Sherman KK, Lashner BA. · Center for Inflammatory Bowel Disease, Department of Gastroenterology/Hepatology-Desk A30, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA. · Dig Dis Sci. · Pubmed #17410449 No free full text.

Abstract: NSAID use has been shown to exacerbate disease activity of inflammatory bowel disease. The detrimental effect of NSAIDs on the ileal pouch has not been characterized. To study the effect of withdrawal of NSAID use on ileal pouch disorders. The study consisted of a cohort of 17 symptomatic patients seen in the Pouchitis Clinic who had ulcerative colitis and ileal pouch-anal anastomosis with chronic (>6 months) daily use of NSAIDs. The patients were treated by withdrawing NSAID use. The Pouchitis Disease Activity Index (PDAI) consisting of symptom, endoscopy and histology scores, and Cleveland Global Quality of Life, Irritable Bowel Disease Quality of Life, and Short Inflammatory Bowel Disease Questionnaire scores were measured before and after a 4-week intervention. The cohort consisted of 11 patients with chronic refractory pouchitis (65%), 2 with acute pouchitis (12%), 1 with cuffitis (6%), 1 with cuffitis and chronic refractory pouchitis (6%), and 2 with irritable pouch syndrome (12%). The withdrawal of NSAID use alone resulted in a significant reduction in the mean PDAI scores of -3.6 +/- -3.0 (p<0.02) and a significant improvement in mean quality-of-life scores (p<0.05). Patients with pouch disorders who regularly used NSAIDs appeared to benefit from the complete cessation of such agents, suggesting an association between NSAID use and pouch disorders.

Shen B, Fazio VW, Remzi FH, Brzezinski A, Bennett AE, Lopez R, Hammel JP, Achkar JP, Bevins CL, Lavery IC, Strong SA, Delaney CP, Liu W, Bambrick ML, Sherman KK, Lashner BA. · Department of Gastroenterology/Hepatology, Center for Inflammatory Bowel Disease, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA. · Clin Gastroenterol Hepatol. · Pubmed #16431309 No free full text.

Abstract: BACKGROUND & AIMS: Although pouchitis is considered the most common adverse sequela of ileal pouch-anal anastomosis (IPAA), inflammatory and noninflammatory conditions other than pouchitis are increasingly being recognized. The risk factors for these non-pouchitis conditions, including Crohn's disease (CD) of the pouch, cuffitis, and irritable pouch syndrome (IPS), have not been studied. The aim of this study was to assess risk factors for inflammatory and noninflammatory diseases of IPAA in a tertiary care setting. METHODS: The study consisted of 240 consecutive patients who were classified as having healthy pouches (N = 49), pouchitis (N = 61), CD of the pouch (N = 39), cuffitis (N = 41), or IPS (N =50). Demographic and clinical features were assessed to determine risk factors for each of these conditions by using logistic regression analysis. RESULTS: Risk factors remaining in the final logistic regression models were for pouchitis: IPAA indication for dysplasia (odds ratio [OR], 3.89; 95% confidence interval [CI], 1.69-8.98), never having smoked (OR, 5.09; 95% CI, 1.01-25.69), no use of anti-anxiety agents (OR, 5.19; 95% CI, 1.45-18.59), or use of NSAIDs (OR, 3.24; 95% CI, 1.71-6.13); for CD of the pouch: a long duration of IPAA (OR, 1.20; 95% CI, 1.12-1.30) and current smoking (OR, 4.77; 95% CI, 1.39-16.25); for cuffitis: arthralgias (OR, 4.13; 95% CI, 1.91-8.94) and younger age (OR, 1.16; 95% CI, 1.01-1.33); and for IPS: use of antidepressants (OR, 4.17, 95% CI, 1.95-8.92) or anti-anxiety agents (OR, 3.21; 95% CI, 1.34-7.47). CONCLUSIONS: The majority of risk factors for the 4 inflammatory and noninflammatory conditions of IPAA are different, suggesting that each of these diseases has a different etiology and pathogenesis. The identification and modification of these risk factors might help patients and clinicians to make a preoperative decision for IPAA, reduce IPAA-related morbidity, and improve response to treatment.

Hartley JE, Fazio VW, Remzi FH, Lavery IC, Church JM, Strong SA, Hull TL, Senagore AJ, Delaney CP. · Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA. · Dis Colon Rectum. · Pubmed #15622572 No free full text.

Abstract: PURPOSE: Ileal pouch-anal anastomosis has come to represent the procedure of choice for patients requiring surgery for mucosal ulcerative colitis. In contrast, a proven diagnosis of Crohn's disease is generally held to preclude ileal pouch-anal anastomosis. However, patients with ileal pouch-anal anastomosis for apparent mucosal ulcerative colitis who are subsequently found to have Crohn's disease have a variable course. We reviewed our experience in this scenario to determine whether selected patients with Crohn's disease may be candidates for ileal pouch-anal anastomosis. METHODS: A retrospective review of the prospectively maintained ileal pouch-anal anastomosis database was undertaken to identify patients with a diagnosis of Crohn's disease after ileal pouch-anal anastomosis. Clinical outcome and quality-of-life data were obtained from the database and chart review. End points were the development of recrudescent Crohn's disease, pouch failure, and quality of life and functional outcome at the time of data collection. Differences between groups were calculated using the chi-squared test. Cumulative incidence of recrudescent Crohn's disease and pouch loss were calculated by the Kaplan-Meier method. Factors predictive of development of recrudescent Crohn's disease and pouch loss were examined by univariate analysis. RESULTS: Sixty patients (32 females; median age, 33 (range, 15-74) years) who underwent ileal pouch-anal anastomosis for mucosal ulcerative colitis subsequently had that diagnosis revised to Crohn's disease. Median follow-up of all patients was 46 (range, 4-158) months at time of data collection by which time 21 patients (35 percent) had developed recrudescent Crohn's disease. No pre-ileal pouch-anal anastomosis factors examined were predictors of the development of recrudescent Crohn's disease on univariate analysis. Median follow-up of the latter group was 63 (range, 0-132) months from time of diagnosis, by which time six patients underwent pouch excision and another patient was permanently defunctioned. The overall pouch loss rate for the entire cohort was 12 percent and 33 percent for those with recrudescent Crohn's disease. Median daily bowel movements in those with ileal pouch-anal anastomosis in situ at the time of data collection was 7 (range, 3-20), with 50 percent of patients rarely or never experiencing urgency and 59 percent reporting perfect or near perfect continence. Median quality of life, health, and happiness scores were 9.9 and 10 of 10. CONCLUSIONS: The secondary diagnosis of Crohn's disease after ileal pouch-anal anastomosis is associated with protracted freedom from clinically evident Crohn's disease, low pouch loss rate, and good functional outcome. Such results only can be improved by the continued development of medical strategies for the long-term suppression of Crohn's disease. These data support a prospective evaluation of ileal pouch-anal anastomosis in selected patients with Crohn's disease.

Baixauli J, Delaney CP, Wu JS, Remzi FH, Lavery IC, Fazio VW. · Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA. · Dis Colon Rectum. · Pubmed #14719144 No free full text.

Abstract: PURPOSE: Disconnection of an ileal pouch-anal anastomosis with repeat ileal pouch-anal anastomosis has been proposed for treatment of ileal pouch-anal anastomosis failure caused by septic or functional complications. We report our experience with repeat ileal pouch-anal anastomosis, and document functional outcome and quality of life. METHODS: Of 101 patients undergoing laparotomy, ileoanal disconnection, and repeat ileal pouch-anal anastomosis, 80 were referred from other institutions. Indications included: chronic anastomotic leak (n=27), perineal or pouch-vaginal fistula (n=47), anastomotic stricture (n=22), dysfunction/long efferent limb of S-pouch (n=36), and previous ileal pouch-anal anastomosis excision or exclusion (n=6). In 64 cases a "septic" indication was observed. Pathologic features of Crohn's disease were present in 4 patients preoperatively and 15 more after repeat ileal pouch-anal anastomosis. Four patients had clinical features of Crohn's disease. RESULTS: Three patients had no ileostomy, and 82 patients had temporary ileostomy closure. Of these, 82 percent have a functioning pouch, with a median follow-up of 32 functioning months. Two were rediverted and 13 had the pouch excised. Five-year pouch survival was 74 percent, higher for ulcerative colitis (79 percent) than Crohn's disease (53 percent; P=0.06). No differences were seen between those having repeat ileal pouch-anal anastomosis for septic or nonseptic indications, or whether using a new or repaired pouch. Patients defecated 6.3 +/- 2.8 (mean +/- standard deviation) times per day, and 2 +/- 1.9 per night. Thirty-five percent of patients never described urgency. Fecal seepage occurred in 50 percent during the day and 69 percent at night. Using the Cleveland Global Quality of Life Score to assess the patient's quality of life, health, level of energy, and happiness with surgery (each scored from 0-10), quality of life was 8.2 +/- 1.6, and happiness with surgery was 9 +/- 2. Ninety-seven percent would undergo repeat ileal pouch-anal anastomosis again, and 99 percent would recommend it to others. CONCLUSIONS: Repeat ileal pouch-anal anastomosis is a valid alternative for patients with ileal pouch-anal anastomosis failure. A controlled septic condition should not preclude salvage surgery. Although pouch failure occurs more frequently than after primary ileal pouch-anal anastomosis, patient satisfaction and quality of life are high.

Fazio VW, Tekkis PP, Remzi F, Lavery IC, Manilich E, Connor J, Preen M, Delaney CP. · Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA. · Ann Surg. · Pubmed #14530732 links to  free full text

Abstract: OBJECTIVE: To identify risk factors associated with ileal pouch failure and to develop a multifactorial model for quantifying the risk of failure in individual patients.SUMMARY BACKGROUND DATA Ileal pouch anal anastomosis (IPAA) has become the treatment choice for most patients with ulcerative colitis and familial adenomatous polyposis who require surgery. At present, there are no published studies that investigate collectively the interrelation of factors related to ileal pouch failure, nor are there any predictive indices for risk stratification of patients undergoing IPAA surgery. METHODS: Data from 23 preoperative, 7 intraoperative, and 10 postoperative risk factors were recorded from 1,965 patients undergoing restorative proctocolectomy in a single center between 1983 and 2001. Primary end point was ileal pouch failure during the follow-up period of up to 19 years. The "CCF ileal pouch failure" model was developed using a parametric survival analysis and a 70%:30% split-sample validation technique for model training and testing. RESULTS: The median patient follow-up was 4.1 year (range, 0-19 years). Five-year ileal pouch survival was 95.6% (95% CI, 94.4-96.7). The following risk factors were found to be independent predictors of pouch survival and were used in the final multivariate model: patient diagnosis, prior anal pathology, abnormal anal manometry, patient comorbidity, pouch-perineal or pouch-vaginal fistulae, pelvic sepsis, anastomotic stricture and separation. The model accurately predicted the risk of ileal pouch failure with adequate calibration statistics (Hosmer Lemeshow chi2 = 3.001; P = 0.557) and an area under the receiver operating characteristics curve of 82.0%. CONCLUSIONS: The CCF ileal pouch failure model is a simple and accurate way of predicting the risk of ileal pouch failure in clinical practice on a longitudinal basis. It may play an important role in providing risk estimates for patients wishing to make informed choices on the type of treatment offered to them.

Delaney CP, Fazio VW, Remzi FH, Hammel J, Church JM, Hull TL, Senagore AJ, Strong SA, Lavery IC. · Departments of *Colorectal Surgery. · Ann Surg. · Pubmed #12894015 links to  free full text

Abstract: OBJECTIVE To evaluate how age affects functional outcome and quality of life after ileal pouch anal anastomosis (IPAA).SUMMARY BACKGROUND DATA Because of the limited number of older patients undergoing IPAA, it has been difficult to assess functional outcome and quality of life stratified by age.METHODS IPAA was performed in 1895 patients. Patients were stratified by age into <45 (n = 1410), 46-55 (n = 289), 56-65 (n = 154), and more than 65 years (n = 42). Outcome was assessed prospectively. Results are presented at 1, 3, 5, and 10 years after surgery.RESULTS Patients were followed for 4.6 +/- 3.7 years (maximum, 17 years). Pouch failure occurred in 4.1% (pouch excision or permanent diversion). Incontinence and night time seepage were more common in older patients. There were minor differences in the quality of life, health, energy and happiness between age groups, with a slight benefit for those under 45 years. Fourteen percent or fewer patients experienced social, sexual or work restrictions. Overall, 96% of patients were happy to have undergone their surgery, and 98% recommended it to others. Although the respective figures were 89% and 96% in the over-65 age group, the difference was not significant.CONCLUSIONS These data provide a unique assessment of outcome after IPAA at multiple time points. Although functional outcome after IPAA is not as good in older patients, appropriate case selection confers acceptable function and quality of life to patients of all ages.

O'Riordain MG, Fazio VW, Lavery IC, Remzi F, Fabbri N, Meneu J, Goldblum J, Petras RE. · Department of Colorectal Surgery, Cleveland Clinic Foundation, Ohio 44195, USA. · Dis Colon Rectum. · Pubmed #11156448 No free full text.

Abstract: PURPOSE: Preservation of the anal transitional zone during ileal pouch-anal anastomosis is still controversial because of the risk of dysplasia and the theoretical risk of associated cancer. Without long-term follow-up data, the natural history and optimal treatment of anal transitional zone dysplasia are unknown. The aim of this study was to determine the long-term risk of dysplasia in the anal transitional zone and to evaluate the outcome of a conservative management policy for anal transitional zone dysplasia. METHODS: Two hundred ten patients undergoing anal transitional zone-sparing ileal pouch-anal anastomosis for ulcerative or indeterminate colitis between 1987 and 1992 and who were studied with serial anal transitional zone biopsies for at least five years postoperatively were included. Median follow up was 77 (range, 60-124) months. RESULTS: Anal transitional zone dysplasia developed in seven patients 4 to 51 (median, 11) months postoperatively. There was no association with gender, age, preoperative disease duration or extent of colitis, but the risk of anal transitional zone dysplasia was significantly increased in patients with prior cancer or dysplasia in the colon or rectum. Dysplasia was high grade in one and low grade in six. Two patients each with low-grade dysplasia detected on three separate occasions underwent mucosectomy 29 and 38 months after detection of low-grade dysplasia, but no cancer was found. The five other patients with dysplasia on one or two occasions were treated expectantly and were apparently dysplasia-free for a median of 72 (range, 48-100) months. CONCLUSIONS: Anal transitional zone dysplasia after ileal pouch-anal anastomosis is infrequent, is most common in the first two to three years postoperatively and may apparently disappear on repeated biopsy. Anal transitional zone preservation did not lead to the development of cancer in the anal transitional zone after five to ten years of follow-up. Long-term surveillance is recommended to monitor dysplasia. If repeat biopsy confirms persistent dysplasia, anal transitional zone excision with neoileal pouch-anal anastomosis is recommended.