Ulcerative Colitis: Weiss EG

Rosen SA, Wexner SD, Woodhouse S, Colquhoun P, Weiss EG, Nogueras JJ, Efron J, Vernava A. · Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida 33331, USA. · Am Surg. · Pubmed #16044939 No free full text.

Abstract: Although significant work has been presented on this subject in pediatric, infectious disease, and epidemiologic literature, there is a noteworthy lack of information on Escherichia coli O157:H7 in any surgical journals. As this disease can present with signs and symptoms often ascribed to the acute abdomen, it is imperative that the general surgeon, pediatric surgeon, and colorectal surgeon are all familiar with this infection and its clinical ramifications. A case report followed by a review of the literature is presented.

Cohen Z, Senagore AJ, Dayton MT, Koruda MJ, Beck DE, Wolff BG, Fleshner PR, Thirlby RC, Ludwig KA, Larach SW, Weiss EG, Bauer JJ, Holmdahl L. · Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Canada. · Dis Colon Rectum. · Pubmed #15868230 No free full text.

Abstract: INTRODUCTION: Postoperative abdominal adhesions are associated with significant morbidity and mortality, placing a substantial burden on healthcare systems worldwide. Development of a bioresorbable membrane containing up to 23 percent glycerol and chemically modified sodium hyaluronate/carboxymethylcellulose offers ease of handling and has been shown to provide significant postoperative adhesion prevention in animals. This study was designed to assess the safety of glycerol hyaluronate/carboxymethylcellulose and to evaluate its efficacy in reducing the incidence, extent, and severity of postoperative adhesion development in surgical patients. METHODS: Twelve centers enrolled 120 patients with ulcerative colitis or familial polyposis who were scheduled for a restorative proctocolectomy and ileal pouch-anal anastomosis with diverting loop ileostomy. Before surgical closure, patients were randomized to no anti-adhesion treatment (control) or treatment with glycerol hyaluronate/carboxymethylcellulose membrane under the midline incision. At ileostomy closure, laparoscopy was used to evaluate the incidence, extent, and severity of adhesion formation to the midline incision. RESULTS: Data were analyzed using the intent-to-treat population. Treatment with glycerol hyaluronate/carboxymethylcellulose resulted in 19 of 58 patients (33 percent) with no adhesions compared with 6 of 60 adhesion-free patients (10 percent) in the no treatment control group (P = 0.002). The mean extent of postoperative adhesions to the midline incision was significantly lower among patients treated with glycerol hyaluronate/carboxymethylcellulose compared with patients in the control group (P < 0.001). The severity of postoperative adhesions to the midline incision was significantly less with glycerol hyaluronate/carboxymethylcellulose than with control (P < 0.001). Adverse events were similar between treatment and no treatment control groups with the exception of abscess and incisional wound complications were more frequently observed with glycerol hyaluronate/carboxymethylcellulose. CONCLUSIONS: Glycerol hyaluronate/carboxymethylcellulose was shown to effectively reduce adhesions to the midline incision and adhesions between the omentum and small bowel after abdominal surgery. Safety profiles for the treatment and no treatment control groups were similar with the exception of more infection complications associated with glycerol hyaluronate/carboxymethylcellulose use. Animal models did not predict these complications.

Pishori T, Dinnewitzer A, Zmora O, Oberwalder M, Hajjar L, Cotman K, Vernava AM, Efron J, Weiss EG, Nogueras JJ, Wexner SD. · Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida 33331, USA. · Dis Colon Rectum. · Pubmed #15037933 No free full text.

Abstract: INTRODUCTION: The aim of this study was to assess the outcome of patients with indeterminate colitis undergoing double-stapled ileal pouch anal anastomosis. METHODS: A retrospective review of demographic, disease-related, and outcome variables of all patients undergoing double-stapled ileal pouch anal anastomosis from August 1988 to January 2000 was undertaken. All patients were evaluated using the validated American Society of Colon and Rectal Surgeons Fecal Incontinence Severity Index. Patients with familial adenomatous polyposis, those who had undergone pouch revision or had S-configured pouches, and patients with a follow-up of less than three months were excluded from analysis. RESULTS: Three hundred ninety-five patients underwent the double-stapled ileal pouch anal anastomosis; of these 303 patients were included for analysis. The mean duration of follow-up was 40 months. Fifty-six (18.1 percent) had a preoperative diagnosis of indeterminate colitis. Postoperatively, indeterminate colitis was diagnosed in 13 (4.3 percent), mucosal ulcerative colitis in 285 (94 percent), and Crohn's disease in 5 (1.6 percent). The overall complication rate was 37.7 percent, 60 percent, and (30.7) percent in patients with mucosal ulcerative colitis, Crohn's disease, and indeterminate colitis, respectively. Postoperative hemorrhage, abscess, and fistula occurred in 2.4 percent, 6.3 percent, and 3.9 percent, respectively, in patients with mucosal ulcerative colitis, and 0 percent, 15.3 percent, and 7.7 percent, respectively, in patients with indeterminate colitis. Small-bowel obstruction occurred in 8.5 percent, 20 percent, and 7.7 percent of patients with mucosal ulcerative colitis, Crohn's disease, and indeterminate colitis, respectively. Pouchitis occurred in 4.6 percent of patients with mucosal ulcerative colitis but in none of the patients with indeterminate colitis. Dysplasia of the anal transition zone was seen in one patient each with mucosal ulcerative colitis and indeterminate colitis. These patients had consistent follow-up and neither showed any sign of evolution to neoplastic disease. None of the patients with indeterminate colitis had a postoperative diagnosis of Crohn's disease during the follow-up period. Functional outcome was comparable in all three patient groups. CONCLUSION: The outcome of the double-stapled ileal pouch anal anastomosis in patients with indeterminate colitis is similar to that of patients with mucosal ulcerative colitis. Therefore, it is a safe option in patients with indeterminate colitis.

Shawki S, Belizon A, Person B, Weiss EG, Sands DR, Wexner SD. · Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida 33331, USA. · Dis Colon Rectum. · Pubmed #19502852 No free full text.

Abstract: PURPOSE: Restorative proctocolectomy and ileal pouch-anal anastomosis is the current surgical treatment of choice for most patients with ulcerative colitis. Complications of the ileal pouch may necessitate additional operations to salvage the pouch. The aims of this study were to review the outcomes of reoperative restorative proctocolectomy and ileal pouch-anal anastomosis surgery and to define any predictors of successful pouch salvage surgery. METHODS: The medical records of all patients who underwent reoperative ileoanal pouch surgery for either pouch salvage or pouch excision between 1988 and 2007 were reviewed. Successful ileoanal pouch salvage was considered to be an intact functioning pouch, after resolution of problem, with a follow-up of at least six months and good to excellent patient satisfaction and continence. RESULTS: Fifty-one patients underwent reoperation for pouch-related complications (44 mucosal ulcerative colitis, 6 familial adenomatous polyposis, and 1 indeterminate colitis), in addition to 8 patients with Crohn's disease. An additional 17 patients had primary pouch excision. Thirty-eight (74.4 percent) of the 51 patients who underwent pouch salvage had a successful outcome. Twenty-three patients had pouch reconstruction or revision via an abdominal approach with a 69.5 percent success rate. The remainder of patients had local perineal procedures for control of perianal sepsis, with 75 percent success rate. Patients required a mean of 2.1 procedures to achieve pouch salvage; there was no correlation between the number of ileoanal pouch salvage procedures and failure. Crohn's disease was ultimately diagnosed in more than half of the patients who underwent primary pouch excision. Among the patients with Crohn's disease who underwent pouch salvage only three retained their pouches, for a success rate of only 37 percent. CONCLUSION: Ileal pouch-anal anastomosis salvage surgery can save a considerable number of patients from pouch excision and permanent ileostomy. Both local perineal and abdominal approaches yield acceptable results. The choice of procedure is based on the etiology and anatomy of the problem and the surgeon's preference and patient-related factors such as diagnosis.

Pikarsky AJ, Belin B, Efron J, Woodhouse S, Weiss EG, Wexner SD, Nogueras JJ. · Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA. · Int J Colorectal Dis. · Pubmed #16932927 No free full text.

Abstract: The majority of colorectal carcinomas diagnosed are adenocarcinomas. Squamous cell carcinomas (SCC) of the rectum are rare tumors, and were reported as rare complication of inflammatory bowel disease. Surgery is the most effective therapy; and adjuvant chemotherapy and radiotherapy should also be considered. We report two cases of ulcerative colitis-associated SCC of the rectum. The lesions were treated with chemoradiotherapy with complete response.

Zmora O, Khaikin M, Pishori T, Pikarsky A, Dinnewitzer A, Weiss EG, Nogueras JJ, Wexner SD. · Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331, USA. · Int J Colorectal Dis. · Pubmed #16932926 No free full text.

Abstract: INTRODUCTION AND OBJECTIVE: Much debate has revolved around whether patients with mucosal ulcerative colitis (MUC) receiving immunosuppression should be weaned off immunosuppressives before undergoing ileal pouch surgery. Therefore, the aim of this study was to assess the affect of immunosuppressive drugs on postoperative complications after ileoanal pouch surgery. MATERIALS AND METHODS: A retrospective medical record review of patients with MUC who underwent ileal pouch surgery while taking immunosuppressive drugs such as azathioprine, 6-mercaptopurine (6-MP), methotrexate, and cyclosporin A was performed. Postoperative complications in the study group were compared to three matched groups: patients with MUC who had ileoanal pouch surgery while taking systemic steroids, patients with MUC not receiving any immunosuppressive drugs, and patients with familial adenomatous polyposis. RESULTS: Twenty-two patients with MUC who underwent ileoanal pouch surgery while taking immunosuppressive drugs were identified from a prospectively entered database of patients who had this surgery between 1988 and 2005. All but two patients underwent temporary fecal diversion. Fifteen patients were taking 6-MP or azathioprine; six were on cyclosporine A, and one both on azathioprine and cyclosporine A. Fifteen patients were also taking steroids at the time of ileoanal pouch surgery. Early (within 30 days of surgery) and late complications occurred in 36 and 50% of the study group patients, respectively, but did not significantly differ from a matched group of patients with MUC who did not take immunosuppressive drugs. Patients with familial adenomatous polyposis had a significantly lower long-term complication rate. CONCLUSION: This retrospective case-matched study suggests that the use of immunosuppressive drugs and cyclosporine A may not be associated with an increased rate of complications after ileoanal pouch surgery.

Tsujinaka S, Ruiz D, Wexner SD, Baig MK, Sands DR, Weiss EG, Nogueras JJ, Efron JE, Vernava AM. · Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA. · J Am Coll Surg. · Pubmed #16735205 No free full text.

Abstract: BACKGROUND: Pouch-vaginal fistula (PVF) is a devastating complication after restorative proctocolectomy with ileal pouch anal anastomosis (IPAA). The aim of this study was to evaluate the surgical management of PVF. METHODS: After Institutional Review Board approval, all patients treated for PVF between 1988 and 2003 were retrospectively reviewed. Success of treatment was defined as the complete absence of symptoms or no radiologic evidence of fistula. RESULTS: The study included 23 female patients; indications for IPAA were mucosal ulcerative colitis in 20 (87%), indeterminate colitis in 1 (4.3%), and familial adenomatous polyposis in 2 (8.7%) patients. Seven patients with mucosal ulcerative colitis were postoperatively diagnosed with Crohn's disease. Mean time interval from initial IPAA to development of symptomatic fistula was 17.2 months. Mean number of surgical treatments was 2.2. Overall, success was achieved in 17 (73.9%) patients at a mean followup of 52.3 months. Fistulas in patients with Crohn's disease occurred relatively late after IPAA (p = 0.015) and required a median of three (p = 0.001) surgical procedures, compared with patients without Crohn's disease. Pelvic sepsis after original IPAA occurred in eight (35.8%) patients, four (50%) of whom ultimately required pouch excision. CONCLUSIONS: Fecal diversion and local procedures are effective in the majority of patients with PVF after IPAA. Patients with Crohn's disease tend to have a delayed onset of fistula occurrence and require more extensive surgical management. Pelvic sepsis can be a predictive factor of poor outcomes.

Baig MK, Weiss EG, Nogueras JJ, Wexner SD. · Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331, USA. · Am J Surg. · Pubmed #16647367 No free full text.

Abstract: The surgical option of choice in most patients with mucosal ulcerative colitis or familial adenomatous polyposis is restorative proctocolectomy with ileal pouch anal anastomosis. The tension-free anastomosis is one of the most critical steps but may be technically difficult or impossible in some patients because of shortened small bowel mesentery. Various techniques have been described to increase the length of small bowel mesentery. These techniques usually involve selective division of mesenteric blood vessels and meticulous dissection. We describe a new technique of stepladder transverse, transmesenteric incisions in the avascular windows of small bowel mesentery. This provides additional small bowel length without compromising blood supply to the pouch and a simple and safe method of increasing the length of small bowel mesentery. To date, no complications have been reported using this technique.

Dinnewitzer AJ, Wexner SD, Baig MK, Oberwalder M, Pishori T, Weiss EG, Efron J, Nogueras JJ, Vernava AM. · Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida 33331, USA. · Colorectal Dis. · Pubmed #16630230 No free full text.

Abstract: BACKGROUND: There is no general consensus regarding the timing of restorative proctocolectomy (RPC) in patients who have undergone subtotal colectomy with end ileostomy (STC). The aim of this study was to determine the impact of timing of RPC in patients who have undergone subtotal colectomy and end ileostomy for inflammatory bowel disease (IBD). METHODS: A retrospective medical record review of patients who had undergone RPC after STC was undertaken. Patients were divided into 3 groups according to timing of the completion proctectomy: <or= 3 months, 4-7 months and > 7 months. RESULTS: From 1990 to 2000, 91 patients had undergone RPC after STC for IBD. There were no statistically significant differences among the three groups relative to mean age, gender, final diagnosis, duration of disease, body mass index, comorbidity, extraintestinal manifestations, use of immunuosuppressives, or operative time. The number of intra-operative complications were significantly higher in the <or= 3 month group compared to the other groups. There was no significant difference in the overall incidence of postoperative complications among the 3 groups. Postoperative fistulas were significantly more common after RPC in Groups 1 and 2 as compared to Group 3. CONCLUSION: Restorative proctocolectomy performed within 3 months after the initial subtotal colectomy was associated with a significant increase in the incidence of intra-operative complications. Although this increase was not statistically significant, there was a significantly higher incidence of fistula formation when RPC was undertaken at up to 7 months after the subtotal colectomy for IBD. Thus, if possible, early RPC after subtotal colectomy should be discouraged.

Sengul N, Wexner SD, Hui SM, Baig MK, Thomas N, Connor J, Weiss EG, Nogueras JJ, Berho M. · Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA. · Tech Coloproctol. · Pubmed #16528486 No free full text.

Abstract: BACKGROUND: Pouchitis is a common complication following restorative proctocolectomy with ileal pouch anal anastomosis (RPC-IPAA) for mucosal ulcerative colitis (MUC). The aim of this study was to determine if perioperative anatomic extent and severity of disease are predictors of pouchitis. METHODS: All consecutive patients who underwent RPC-IPAA for MUC between 1988 and 2002 were retrospectively studied. Pouchitis was classified as acute, recurrent or refractory. Colectomy specimen slides were histopathologically evaluated by a single blinded pathologist (MB), who assessed extent and severity of disease. RESULTS: Of 112 patients assessed, 70 (62.5%) had some form of pouchitis at a median follow-up of 38 months (range, 1-204 months). No association was found between the extent or severity of disease and subsequent development of acute or chronic pouchitis. A positive correlation was found between the histopathologic score and the occurrence of clinical pouchitis (p=0.014). The presence of colonic metaplasia in the pouch biopsy was significantly correlated with a histopathologic diagnosis of pouchitis (p<0.0001, r=-0.449). CONCLUSIONS: Following RPC for MUC, the extent and severity of disease do not predict the subsequent development of pouchitis.

Ho KS, Chang CC, Baig MK, Börjesson L, Nogueras JJ, Efron J, Weiss EG, Sands D, Vernava AM, Wexner SD. · Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida 33331, USA. · Colorectal Dis. · Pubmed #16466566 No free full text.

Abstract: OBJECTIVE: Proctocolectomy and ileal pouch anal anastomosis (IPAA) has become the standard surgery for patients with mucosal ulcerative colitis (MUC). Although there is no absolute age limitation, there are concerns as to its use in elderly patients due to the risks of potential complications and poor function. The aim of this study was to assess the complications and outcome of patients over the age of 70 years with MUC who underwent IPAA. Results in these patients were compared to the results in a group of patients aged less than 70 years who had IPAA. METHODS: After Institutional Review Board approval, a retrospective review of the medical records of patients with MUC who underwent IPAA was undertaken. These patients were divided into four age groups: <30 years of age, 30-49 years, 50-69 years, >or=70 years. RESULTS: From 1989 to 2001, 330 patients underwent IPAA for preoperative clinical and histopathological and postoperative histopathologically confirmed MUC; 17 were aged>or=70 years. The mean hospital stay was 5.8 (SEM 0.7) days in the patients aged<70 years and 6.0 (SEM 0.4) days in the patients aged>or=70 years (P=0.911). Postoperative complications occurred in 39% of patients>or=70 years and in 40% in the <70 years group (P=0.08). Pouch failure occurred in two (11.8%) patients>or=70 years and in 6 (1.9%)<70 (P=0.2). CONCLUSION: IPAA is a safe and feasible option in MUC patients over the age of 70 with functional results similar to results seen in younger patients.

Saigusa N, Choi HJ, Wexner SD, Woodhouse SL, Singh JJ, Weiss EG, Nogueras JJ, Belin B. · Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA. · Colorectal Dis. · Pubmed #12780905 No free full text.

Abstract: PURPOSE: This study aims to assess the correlation between the tissue types found in the circular stapler donut at the time of initial double-stapled ileal pouch-anal anastomosis (DS-IPAA) and during subsequent periodic routine random biopsy. Secondarily, we sought to assess the risk of dysplasia, carcinoma or mucosal ulcerative colitis (MUC) recurrence in the retained mucosa. METHODS: The pathology reports of 91 patients (48 males, 43 females) who were operated upon for MUC from September 1988 to June 1997 and were reviewed and had two follow up visits for biopsy. The histological features of the distal donuts and biopsies of retained mucosa obtained at yearly interval follow-up were assessed in order to determine the epithelial tissue type (columnar, transitional and squamous), inflammation, recurrence of MUC and presence of dysplasia or malignancy. RESULTS: Median age at surgery was 43 (range 15-71) years and duration of MUC was 9.6 (range 0.3-42) years prior to surgery. The anastomosis was performed at a median height of 1.0 (range 0-2.5) cm cephalad to the dentate line and biopsy follow-up was undertaken at median 34 (range 2-110) months after DS-IPAA. The distal donuts were analysed in all cases, as were 305 follow-up biopsies (median 3.4; range 1-7 per patient). Although columnar epithelium (CE) was found in 62 (68%) donuts, it was absent on follow-up biopsy in 16 (26%) of these patients. Conversely, although no CE was identified in 29 (32%) donuts, it was identified in 11 (38%) of these patients during follow-up biopsy. CE in the donut was a significant predictor of CE in subsequent biopsies (P = 0.0012). The histological features consistent with MUC were seen in the biopsies from the retained mucosa in 15 (16%) patients from 0.3 to 7.6 years after DS-IPAA. While eight (9%) patients exhibited dysplasia or adenocarcinoma in the excised colon or rectum, none of the patients had either dysplastic changes or carcinoma within the retained mucosal biopsies. CONCLUSION: The correlation between CE in the circular stapler donut and at follow-up biopsy was high. However since CE developed in some patients in whom no CE was present in the distal donuts, regardless of the epithelial tissue type finding at the time of DS-IPAA, periodic follow-up biopsy should be obtained.

Saigusa N, Belin BM, Choi HJ, Gervaz P, Efron JE, Weiss EG, Nogueras JJ, Wexner SD. · Department of Colorectal Surgery, Cleveland Clinic Florida, Weston 33331, USA. · Dis Colon Rectum. · Pubmed #12576889 No free full text.

Abstract: PURPOSE: The rectoanal inhibitory reflex has an important role in fecal sampling and discrimination of rectal contents. The aim of this study was to determine the significance of rectoanal inhibitory reflex after restorative proctocolectomy with ileal pouch-anal anastomosis for mucosal ulcerative colitis. METHODS: The medical records of 345 patients who underwent ileal pouch-anal anastomosis from September 1988 to May 1999 were retrospectively reviewed. One hundred patients who underwent double-stapled ileal pouch-anal anastomosis and had anorectal physiology testing within 3 months before surgery as well as after ileostomy closure (mean, 23.1; range, 3-77 months) were analyzed. Anorectal physiology testing included detecting the presence of the rectoanal inhibitory reflex, sensory threshold volume, and rectal or pouch capacity and compliance. Parameters to determine incontinence included daytime and nocturnal bowel movement frequency, nocturnal spotting, status of continence for solid or liquid stool, gas, use of pads, and lifestyle alteration were surveyed in 62 of the 100 patients at a mean of 3.9 (range, 1-9.1) years to determine the incontinence score. RESULTS: Whereas the rectoanal inhibitory reflex was noted in 96 (96 percent) patients before surgery, it was found in only 53 (53 percent) after ileostomy closure (P < 0.0001). Incontinence status data was available in only 62 of the 100 patients (32 RAIR-positive; 30 RAIR-negative). There were no significant differences between the rectoanal inhibitory reflex-positive and the rectoanal inhibitory reflex-negative groups relative to the interval between surgery and manometry (22 vs 25 months), postoperative threshold sensation volume (32 vs 31 ml), postoperative compliance (19 vs 12 cm H(2)O/ml), postoperative capacity (85 66 ml), daytime/nighttime stool frequency (6.2/2 vs 5.5/1.5), or postoperative incontinence score (3.9 vs 1.8). However, there were significant differences relative to the incidence of nocturnal soiling (12/30 (40 percent) 23/32 (72 percent), P = 0.0012) favoring the presence of the rectoanal inhibitory reflex. CONCLUSION: Preservation of the rectoanal inhibitory reflex correlated with a decrease in the incidence of nocturnal soiling after double-stapled ileoanal reservoir construction.

Choi HJ, Saigusa N, Choi JS, Shin EJ, Weiss EG, Nogueras JJ, Wexner SD. · Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA. · Int J Colorectal Dis. · Pubmed #12548412 No free full text.

Abstract: BACKGROUND AND AIMS: The double-stapled ileoanal reservoir (DSIAR) has become a preferred method for ileal pouch anal anastomosis in restorative proctocolectomy. This investigation assessed the relative ratio of epithelial tissue types within the anal transition zone after a DSIAR and reviewed functional physiological differences. PATIENTS AND METHODS: All 138 patients who underwent restorative proctocolectomy with a DSIAR for mucosal ulcerative colitis were stratified into two groups according to histological evidence of epithelium types in the distal excised rectal donut. In group I a squamous or a squamous mixed with columnar epithelium was present (n=40) whereas in group II only columnar epithelium was seen (n=98). Anal physiological parameters were measured by anal manometry preoperatively, prior to ileostomy closure, and 1 year after surgery. RESULTS: None of the preoperative resting and squeeze pressure parameters showed a significant difference between the two groups. Postoperative mean and maximal resting pressures were significantly decreased in both groups. Postoperative mean and maximum squeeze pressures were decreased in group I. Postoperative mean length of the high-pressure zone tended to be decreased in both groups. The decrease in rectoanal inhibitory reflex was significant in both groups. Postoperative functional parameters measured as maximal tolerable volume and compliance were significantly improved from preoperative values in both groups. CONCLUSION: The tissue type in the anal transitional zone after DSIAR has a wide variability at a similar level (height) of the anastomosis. However, these different epithelial types were not associated with substantial physiological functional differences. Thus, if technically feasible, it is desirable for DSIAR to construct the anastomosis as close to the dentate line as possible.

Zmora O, Efron JE, Nogueras JJ, Weiss EG, Wexner SD. · Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale, Florida 33331, USA. · Dis Colon Rectum. · Pubmed #11584205 No free full text.

Abstract: PURPOSE: Complications of the ileal pouch with ileoanal anastomosis are associated with poor function and diminished quality of life; often, these complications may require surgery to salvage the pouch. The aims of this study were to review our experience with reoperative ileoanal pouch surgery and to define any predictors of pouch salvage surgery. METHODS: Between 1991 and 1999, the medical records of all patients who underwent reoperative ileoanal pouch surgery for either pouch salvage or pouch excision were reviewed; any minor local procedures were excluded. Successful ileoanal pouch salvage was considered to be an intact and functioning pouch, with acceptable patient satisfaction and good control. RESULTS: Thirty-two patients underwent reoperative ileoanal pouch surgery, 25 for attempted pouch salvage and 10 for pouch excision (3 patients were included in both groups). Five patients (20 percent) had pouch reconstruction, 1 of which was successful; 8 (32 percent) had pouch advancement, with a 62 percent success rate; and 16 (64 percent) had local perianal procedures for control of perianal sepsis, with a 75 percent success rate (4 of these required further surgery). The overall success rate of ileoanal pouch salvage surgery was 84 percent, with 64 percent of patients having acceptable function. There was no correlation between the number of ileoanal pouch salvage procedures and failure. Four (40 percent) of the 10 patients who had pouch excision were ultimately diagnosed with Crohn's disease. CONCLUSIONS: Ileoanal pouch salvage surgery is often successful and, in motivated patients without Crohn's disease, is worthwhile. Pouch advancement or local perianal repair yielded better results than did pouch reconstruction. Patients diagnosed with Crohn's disease after ileoanal pouch construction may be best suited for pouch excision when complications occur.

Efron JE, Uriburu JP, Wexner SD, Pikarsky A, Hamel C, Weiss EG, Nogueras JJ. · Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale, FL 33309, USA. · Obes Surg. · Pubmed #11433894 No free full text.

Abstract: BACKGROUND: Obesity is a relative contraindication to performing restorative proctocolectomy. The aim of this study was to assess the morbidity and functional results after restorative proctocolectomy in obese patients as compared to a matched cohort of non-obese patients. METHODS: 334 patients who had restorative proctocolectomy were reviewed; obesity was defined as a body mass index (BMI) greater than or equal to 30 kg/m2. 31 obese patients were matched to 31 non-obese patients for age, gender, steroid use, and diagnosis. Operative time, length of hospitalization, and both perioperative (< 6 weeks) and long-term morbidity (> 6 weeks), especially sepsis, were evaluated. RESULTS: The BMI was significantly higher in the obese group (33.7 vs 23.2) (p < 0.0001), and no difference was found between the obese and non-obese groups relative to the matched parameters of age, gender, steroid use and diagnosis. There was no difference in the rate of mucosectomy performed between the obese and non-obese patients (9.6% vs 3.2%, p = NS). 16% of the obese patients underwent one stage restorative proctocolectomies as compared to 10% in the non-obese group. Operative time was longer in the obese group (229 min vs 196 min; p = 0.02), but overall hospital length of stay was similar (9.7 days vs 7.7 days; p = 0.13). Perioperative morbidity was higher in obese patients (32% vs 9.6%, p = 0.058). However, there was no statistical significance in long-term morbidity (23% vs 32%, p = 0.57) at a mean follow-up of 51 months in the obese group and 53 months in the non-obese group. Obese patients had more stomal complications (10 vs 0%) and incisional hernias (13 vs 3%) (p = NS). Overall the pelvic sepsis-rate was significantly higher in the obese group (16 vs 0%; p < 0.05). 60% of the obese patients who developed pelvic sepsis had pouch-anal anastomosis performed without proximal fecal diversion. Mean bowel movements/24 hours, pad use, nocturnal evacuation, accidents/24 hours and incontinence scores were not statistically significant between the groups. CONCLUSION: Obese patients have a higher rate of pelvic sepsis and peri-operative morbidity when compared to a matched non-obese cohort of patients; however, the functional outcome of restorative proctocolectomy in obese patients is not significantly different than in non-obese patients.

Choi JS, Potenti F, Wexner SD, Nam YS, Hwang YH, Nogueras JJ, Weiss EG, Pikarsky AJ. · Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale 33309, USA. · Dis Colon Rectum. · Pubmed #11052517 No free full text.

Abstract: 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.