Ulcerative Colitis: MacLean AR

Ball CG, MacLean AR, Buie WD, Smith DF, Raber EL. · Department of Surgery, Foothills Medical Centre, University of Calgary, 1403-29 Street N.W., Calgary, AB, T2N 2T9, Canada. · Surg Today. · Pubmed #17593473 No free full text.

Abstract: PURPOSE: Portal vein thrombi (PVT) have recently been linked to ileal pouch-anal anastomosis (IPAA). We assessed the rate of PVT in patients who underwent IPAA and attempted to identify the associated features. METHODS: We reviewed all patients who underwent IPAA at our hospital between 1997 and 2002, noting demographic, operative, and clinical data. Computed tomography (CT) scans were independently re-reviewed by two radiologists blinded to patient data. Scans were designated as positive, negative, or indeterminate for PVT. RESULTS: A total of 112 patients underwent IPAA for ulcerative colitis, 28 (25%) of whom had a CT scan done within 8 weeks postoperatively. The indications for CT included prolonged ileus (32.1%), abdominal pain (28.6%), and fever (17.9%). On examining the CT scans, 39% were positive, 14% were indeterminate, and 46% were negative for PVT. There was no association between PVT and pelvic sepsis. Within a mean follow-up of 36.2 months, 15.4% patients without PVT had suffered pouchitis compared with 25% of those with indeterminate scans and 45.5% of those with PVT. CONCLUSIONS: Portal vein thrombi are a common finding in the subset of patients who require a CT scan after IPAA. Patients who suffer PVT have a higher incidence of postoperative pouchitis. Thus a prospective evaluation of the risk of PVT and its association with pouchitis is warranted.

MacLean AR, Lilly L, Cohen Z, O'Connor B, McLeod RS. · Department of Surgery, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada. · Dis Colon Rectum. · Pubmed #12907911 No free full text.

Abstract: PURPOSE: The purpose of this study was to determine the outcome of patients with inflammatory bowel disease who underwent liver transplantation for primary sclerosing cholangitis. METHODS: All patients who underwent liver transplantation for primary sclerosing cholangitis at our institution were identified. A review of patients' hospital and office charts was performed; all patients were then contacted, and a detailed survey was administered by telephone. RESULTS: Sixty-nine patients were identified. There were 53 males (76.8 percent) and 16 females, with a mean age of 45.3 (+/- 13.3) years. Fifty-two (75.4 percent) of the 69 patients had documented inflammatory bowel disease; of these, 40 had ulcerative colitis (76.9 percent), 11 had Crohn's disease, and 1 had indeterminate colitis. Thirty-one patients (60 percent) were diagnosed with inflammatory bowel disease before primary sclerosing cholangitis, with a mean interval to diagnosis of primary sclerosing cholangitis of 10.8 (+/- 10.3) years. Seven patients had both diagnoses made at roughly the same time, and 14 patients initially were diagnosed with primary sclerosing cholangitis and subsequently were found to have inflammatory bowel disease, with a mean interval of 5.2 (+/- 4.4) years; 5 (35.7 percent) of those 14 patients were only diagnosed with inflammatory bowel disease after their liver transplant. The mean time from diagnosis of primary sclerosing cholangitis to liver transplantation was 6.1 (+/- 4.9) years. Since their transplant, 30.8 percent of patients rated their colitis as worse, 38.5 percent felt it was unchanged, and 30.8 percent felt that their colitis was better controlled. Eight (15.4 percent) of the 52 patients with inflammatory bowel disease denied having any knowledge of an increased risk of colorectal neoplasia. Four patients have required colectomy for colorectal neoplasia after liver transplantation, at a mean of 4.7 years after transplantation. Of the patients with inflammatory bowel disease, 42 (80.1 percent) had at least 1 posttransplant surveillance colonoscopy. Eight of the remaining ten patients had a colectomy, leaving only two patients (3.8 percent) who had not been surveyed. However, only 32 (61.5 percent) of the patients with inflammatory bowel disease have been on a surveillance regimen that would approximately conform to current screening recommendations. CONCLUSIONS: The activity of inflammatory bowel disease after transplantation is highly variable. Patients appeared to lack knowledge of their increased risk for colorectal neoplasia. Colorectal cancer is an uncommon but important complication in patients after liver transplantation for primary sclerosing cholangitis, and ongoing surveillance is required. Patients may require education to increase their awareness of the cancer risk and compliance with surveillance.

MacLean AR, O'Connor B, Parkes R, Cohen Z, McLeod RS. · Inflammatory Bowel Disease Research Unit, Department of Surgery, Department of Health, Health Policy, Management, and Evaluation, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada. · Dis Colon Rectum. · Pubmed #12130874 No free full text.

Abstract: PURPOSE: Salvage procedures for failed ileal pouch-anal anastomoses frequently require total reconstruction with a combined abdominal and perineal approach. The aim of this study was to determine the indications for surgery and the outcomes in this group of patients. METHODS: All patients who underwent combined abdominal and perineal ileal pouch-anal anastomosis reconstruction at the Mount Sinai Hospital between 1982 and 2000 were reviewed. Data were collected prospectively in the inflammatory bowel disease database. RESULTS: Sixty-three reconstructive procedures were performed in 57 patients, with a mean age of 33.9 (+/-10.4) years at the time of reconstruction. There were 14 males. The mean follow-up was 69.1 months. The initial indication for ileal pouch-anal anastomosis was ulcerative colitis in 98 percent. The primary indication for reconstruction was pouch-vaginal fistula in 21 patients, long outlet in 14, pelvic sepsis in 14, ileoanal anastomotic stricture in 5, pouch-perineal fistula in 2, and chronic pouchitis in 1. The mean operative time was four hours (+/-1.1), the average blood loss was 500 mL (+/-400), and the average length of stay was 10.3 days (+/-4.6). All patients had a diverting ileostomy. Forty-two (73.6 percent) of the patients have a functioning pouch. Seven (12.3 percent) patients have had their pouch excised. The ileostomy has not yet been closed in 8 (14 percent) patients; 3 of these patients are awaiting closure, whereas the remaining 5 have a permanently defunctioning ileostomy. Eighty-nine percent have ten or fewer bowel movements per day. No patients are incontinent of stool during the day, whereas two patients are incontinent at night. Seventeen percent complain of frequent urgency. Despite this, more than 80 percent rate their physical and psychological health as good to excellent. CONCLUSION: Reconstructive pouch surgery has a high success rate in experienced hands. The functional results in those whose pouch is in use are good.

MacLean AR, Cohen Z, MacRae HM, O'Connor BI, Mukraj D, Kennedy ED, Parkes R, McLeod RS. · IBD Research Unit, Department of Surgery, Mount Sinai Hospital and University of Toronto, Canada. · Ann Surg. · Pubmed #11807359 links to  free full text

Abstract: 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.