Dozois, Roger R.

AbstractThe aim of this retrospective study was to determine the outcome of patients with a dysfunctional pelvic ileal reservoir in whom disconnection of an ileal pouch-anal anastomosis (IPAA), pouch revision and reanastomosis had been carried out. There were 23 patients (15 women). At the revision operation functional problems were found to be due to a long efferent spout (nine patients), sepsis and/or fistula (four), a redundant blind limb (three), a twisted pouch (three), anastomotic problems (three) or no reservoir (one). The pouch was salvaged in 16 patients and a new pouch was constructed in seven. The pouch-anal anastomosis was resutured in 22 patients and stapled in one. Postoperative complications (all minor) occurred in six patients. Two patients underwent two revisions of IPAA. At a median follow-up of 5 (range 1–10) years, 11 patients reported good to excellent function, five reported fair function and one reported recurrent pouchitis. Revision surgery was unsuccessful in six of 23 patients (three had gross incontinence, two excessive bowel movements and one Crohn's disease), and they subsequently underwent pouch excision. It is concluded that revision of an ileal reservoir and IPAA can be undertaken safely with good results in carefully selected patients.

Abstract Background Ileal pouch–anal anastomosis (IPAA) is performed routinely for chronic ulcerative colitis. Methods Using data from a prospective database and annual standardized questionnaires, functional outcome, complications and quality of life (QoL) after IPAA were assessed. Results Some 1885 IPAA operations were performed for chronic ulcerative colitis over a 20-year period (mean follow-up 11 years). The mean age at the time of IPAA was 34·1 years, increasing from 31·2 years (1981–1985) to 36·3 years (1996–2000). The overall rate of pouch success at 5, 10, 15 and 20 years was 96·3, 93·3, 92·4 and 92·1 per cent respectively. Mean daytime stool frequency increased from 5·7 at 1 year to 6·4 at 20 years (P < 0·001), and also increased at night (from 1·5 to 2·0; P < 0·001). The incidence of frequent daytime faecal incontinence increased from 5 to 11 per cent during the day (P < 0·001) and from 12 to 21 per cent at night (P < 0·001). QoL remained unchanged and 92 per cent remained in the same employment. Seventy-six patients were eventually diagnosed with indeterminate colitis and 47 with Crohn's disease. Conclusion IPAA is a reliable surgical procedure for patients requiring proctocolectomy for chronic ulcerative colitis and indeterminate colitis. The clinical and functional outcomes are excellent and stable for 20 years after operation.

AbstractUseful palliation can often be achieved when standard treatment approaches of external beam irradiation and chemotherapy with or without resection are used for locally advanced primary rectal malignancies. Local control and long‐term survival are achieved in only 10% to 50% of patients, however, due to the limited irradiation tolerance of surrounding organs and tissues. Encouraging trends exist in separate intra‐operative irradiation analyses from Massachusetts General Hospital and Mayo Clinic with regard to improvement in local control and possibly survival of locally advanced rectal lesions, warranting continued evaluation of such approaches. Disease control within the intra‐operative and external irradiation field is decreased, however, when the surgeon is unable to accomplish gross total resection. Therefore it seems reasonable to consistently add 5‐Fluorouracil with or without Leucovorin during external irradiation and to evaluate the use of dose modifiers, such as sensitizers or hyperthermia, in conjunction with intra‐operative irradiation. Since high systemic failure rates exist with both locally advanced primary and recurrent lesions, more effective chemotherapy needs to be evaluated during external irradiation as well as after completion of such. In view of survival advantages with 5‐Fluorouracil plus Leucovorin versus 5‐Fluorouracil alone for metastatic disease, this regimen is currently being employed. Even with locally recurrent lesions, the aggressive multimodality approaches including intra‐operative irradiation have resulted in improved local control, and long‐term survival rates of 20% to 25% versus an expected 5% with conventional techniques in historical series.

AbstractRelapses after “curative resection” of rectal cancer may be localized and thus amenable to surgical treatment. The risk of relapse may be higher than previously believed depending on adequacy and length of follow‐up, the diagnostic modalities used, and the number of autopsies performed. Technical refinements such as a distal margin >2 cm, radical pelvic lymphadenectomy, and high ligation of the inferior mesenteric artery at the aorta do not appear to diminish the risk of recurrence. A wider lateral margin and a more complete excision of the mesorectum may be beneficial, but this is yet unproven. Surgery for isolated, locally recurrent lesions should be limited to carefully selected patients and performed in tertiary centers using a team approach. Whether such radical “salvage” procedures are justifiable merits further careful evaluation.

AbstractApproximately 5% of rectal cancers are locally advanced with adherence to the vagina, uterus, bladder, prostate, or other structures. Sacral involvement is fortunately rare in primary cancers. In about 50% of patients there is histologic confirmation of tumor invasion in the area of adherence. It is important to recognize the nature of these tumors pre‐operatively so that the patient can be prepared for an exenterative procedure should this be necessary. When these tumors are removeden bloc, 5‐year survival rates of 50% can be obtained with survival depending on the presence or absence of regional metastasis and also the presence or absence of histologic tumor invasion into adjacent structures.

AbstractResults from epidemiologic studies have provided insights into the etiology of large bowel cancer. Markedly diverse incidences of colorectal cancer exist in various parts of the world and within different regions of a given country. Studies of migrant populations have revealed a role for environmental factors, particularly dietary, in the etiology of colorectal cancers. Genetic factors and inflammatory bowel disease also place certain individuals at increased risk. Sedentary lifestyle, cholecystectomy, and ureterosigmoidostomy may also increase the risk of developing large bowel cancer.

AbstractThe experience at the Mayo Clinic, Rochester, Minnesota, U.S.A., with abdominal colectomy, mucosal proctectomy, and ileo‐anal anastomosis is now approaching 600 patients. The procedure is safe and, with careful timing and selection of patients, can be performed with minimal mortality. Postoperative morbidity, however, is still considerable, even in the most experienced hands. Increasing experience with the procedure has been shown to be associated with a continuing decline in the incidence of postoperative complications, and a defunctioning ileostomy is still a necessity in the majority of patients.Long‐term functional results of the procedure are satisfactory and have been shown to improve both with the experience of the operator and with the passage of time after surgery. Patient acceptance remains the ultimate sanction, and it appears that the majority of patients are satisfied with their outcome after ileo‐anal anastomosis, with only very few being prepared to consider an alternative. The operation appears to provide a superior quality of life relative to that expected after proctocolectomy and Brooke ileostomy.Not all patients with chronic ulcerative colitis or adenomatosis coli are potential candidates for this procedure, however. The problems of age, obesity, indeterminate colitis and Crohn's disease, co‐existing colorectal neoplasia, technical difficulties at the time of the operation, and the wishes of the patient all must be taken into consideration when assessing the optimal operation in a particular situation. Proctocolectomy with Brooke ileostomy or continent ileostomy and total abdominal colectomy with ileo‐rectal anastomosis both still have roles in the management of diseases such as chronic ulcerative colitis and adenomatosis coli. For a patient who is young, relatively fit, and well motivated and in whom there is little or no doubt about the diagnosis, ileo‐anal anastomosis must be considered as the possible treatment of choice. Increasing experience with the procedure and improvements in functional results seem to be confirming this position.

Abstract Aim The purpose of the study was to determine the risk of postoperative complications and the functional outcome after a hand-sewn ileal pouch–anal anastomosis (IPAA) for ulcerative colitis using a single J-shaped pouch design. Methods Preoperative function, operative morbidity and long-term functional outcome were assessed prospectively in 1310 patients who underwent IPAA between 1981 and 1994 for ulcerative colitis. Results Three patients died after operation. Postoperative pelvic sepsis rates decreased from 7 per cent in 1981–1985 to 3 per cent in 1991–1994 (P=0·02). After mean follow-up of 6·5 (range 2–15) years, the mean number of stools was 5 per day and 1 per night. Frequent daytime and night-time incontinence occurred in 7 and 12 per cent of patients respectively, and did not change over a 10-year period. The cumulative probability of suffering at least one episode of ‘clinical’ pouchitis was 18 and 48 per cent at 1 and 10 years and the cumulative probability of pouch failure at 1 and 10 years was 2 and 9 per cent respectively. Conclusion These results indicate that increased experience decreases the risk of pouch-related complications and that with time the functional results remain stable, but the failure rate increases.